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It’s time we complete the risk assessment of participation in contact sports, especially in that cornerstone of American culture: football. There is good research on the incidence, cost, and long-term consequences of anterior cruciate ligament tears, shoulder dislocations, and ankle sprains. However, we are just starting to elucidate these matters for head trauma, concussion, and chronic traumatic encephalopathy (CTE). CTE is a progressive degenerative disease of the brain found in those with a history of repetitive brain trauma, including symptomatic concussions as well as asymptomatic subconcussive hits to the head.1,2 Originally called “dementia pugilistica,” CTE is associated with memory loss and behavioral and personality changes.6 It is also characterized by atrophy of the cerebral hemispheres and other parts of the brain. The course and sequelae of CTE are very worrisome, emphasizing the desperate need for a better understanding of the risks of repeated brain injury. A recent government-funded study of over 3000 athletes with at least 5 years of play in the National Football League (NFL) showed that these athletes were more than 4 times more likely to die of brain disease than the average American.4 It’s unlikely that football will ever be banned at the professional, college, or high school levels. Even so, there is no doubt that players, parents, coaches, administrators, and medical personnel would like more answers to the questions about the risks of participation.
How dangerous is repeated impact on the developing brain? How old should participants be when they begin to play? Is there a threshold of impact force or number of hits that retard neural development? Can we justify “student athlete” participation if we really do not know the risks that these players are accepting? Fortunately, it appears that many, if not most, players are resistant to the long-term consequences associated with head trauma and contact sports. Evidence for this exists in the millions of athletes who have participated in football, hockey, rugby, and other contact sports without falling victim, at least in an obvious way, to premature brain degeneration.
Clearly, there are behavioral and medical issues in some former players that we must pay close attention to as we research these problems. The recent premature deaths, suicides, deviant behavior, and mental functioning problems of some former professional football players should not be ignored.3 As a society, we need to know why these patterns of self-destruction and depression happen and whether these tragic cases can be prevented. Are there some individuals that are genetically susceptible to head trauma who should not play contact sports? There does appear to be a susceptibility factor that puts some individuals more at risk than others. For example, ApoE genotyping was conducted on some athletes affected by CTE. Fifty percent of these athletes were carriers for ApoE ϵ4, suggesting that it may be a risk factor for developing CTE.6 But are there related problems, such as steroid, alcohol, or illicit drug use, which increase the risk of neural degeneration? Are these risks additive? Can concussions be successfully treated to prevent long-term cumulative consequences?
To answer these questions is no easy task, but there are considerable research efforts now underway that aim to do so. But, as always, when it comes to research, time and money play an important role. Time is essential, as most good clinical studies require long-term assessment and follow-up. When well designed, these studies are very costly but have the potential to address most crucial questions. The costs of these research efforts should be borne by those who benefit financially from the games themselves. The leagues that benefit the most financially, the National Collegiate Athletic Association (NCAA) and the National Football League, should support these efforts to a high degree. And because this is a public health issue, federal research funding agencies should pay close attention to research efforts, demanding and supporting the highest quality studies.
In 1905, after multiple football-related deaths, President Theodore Roosevelt met with representatives from Harvard, Yale, and Princeton universities to persuade them to make football a less violent game. President Roosevelt insisted that universities establish the NCAA to make football safer. Is the central goal of the NCAA still to keep the game safe? Isn’t it reasonable to assume that institutions of higher education insist on adequate research efforts to ensure that the college game is safe? With all the revenue generated by college sports, it’s not clear if enough has been spent on injury research, let alone concussions. To its credit, the NCAA is currently funding a study by 4 institutions: University of California–Los Angeles, University of Michigan, Medical College of Wisconsin, and University of North Carolina at Chapel Hill. This longitudinal study examines the effects of head injuries on 1000 male and female student athletes in 11 sports over their college career.7 The study uses accelerator technologies inside helmets to determine head impact dynamics associated with concussions.
To its credit, the NFL has supported considerable research for quite some time on concussions and has changed many facets of the professional game to decrease the risk of head trauma. In 2010, the NFL donated $1 million to the Center for the Study of Traumatic Encephalopathy.5 This year, the NFL donated $30 million to concussion research at the Foundation for the National Institutes of Health. Are these efforts too little, too late, or not commensurate with the profits gained? These questions are open for discussion.
Today’s athletes are bigger, stronger, and faster than those of the past, making their collisions more violent. The game has changed dramatically over the past several decades! While protective equipment has improved significantly (eg, the helmet), we do not know if technology has kept up with physical development of players and the speed and impact of the game.
It’s time for all that have a stake in the game, financial or otherwise, to fully support research efforts to understand athletes’ susceptibility to head trauma, along with the short- and long-term consequences of such trauma. The warning signs are now perfectly clear. We can no longer ignore them—we need answers now!