In Focus

Brawn and Brains: Looking at NFL Head Injuries

NFL Head Injuries

Any football fan watching a Sunday afternoon game will most likely witness at least one slow‐motion replay of a running back lowering his head as he faces off against a safety, or a defensive end’s helmet colliding with another player’s during a tackle. Fans of professional football bear witness to repeated head trauma during every game. Later in their lives, the football players confront the effects of these hits: health problems such as vertigo and dementia. While some rely on a support network, others struggle. The stories can be tragic, from the suicide of 44‐year old Andre Waters to the 50‐year old Mike Webster, a nine‐time Pro Bowler and Hall of Famer whose mental problems led to his homelessness and premature death.

Recently, however, academic research has started to confirm these anecdotes, uncovering potential links between repetitive head trauma in football and a serious health condition, called chronic traumatic encephalopathy (CTE). Originally associated with boxers, CTE is a type of neurological deterioration caused by repetitive head trauma. For football players, that deterioration often stems from the multiple concussions players suffer, especially those who play in positions where helmet contact is common. The new research has attracted public interest; in the past year alone, news coverage of the issue in popular media has increased; the New York Times frequently publishes articles related to the effects of head injuries in sports, and in November 2010, Sports Illustrated published a cover story on concussions. Previously a minor issue addressed within the National

Football League and its Players’ Association, the long‐term effects of repetitive head injuries has become a contentious issue for sports fans, commentators, the U.S. government, and for the National Football League. For years, the NFL commissioned its own studies that negated the effect of head trauma. After pressure from two Congressional hearings in the past year, the NFL has tacitly changed its stance. During the 2010‐2011 season, the league has started to change its internal policies towards compensation and the treatment of ex‐NFL players suffering from CTE. The NFL’s new policies may also reflect the fact that their base of football fans are slowly coming to terms with the mounting evidence that professional football causes permanent physical harm, and considering what it means to support a sport with those consequences. In the meantime, CTE researchers are still in the process of collecting enough evidence to build a conclusive link between the disease and football.

As of July 2009, only 51 cases of CTE have been neuropathologically confirmed, a number constrained by the fact that CTE can only be diagnosed post‐mortem. 90% of those diagnosed were former athletes, of which 11% were former football players [1]. From these confirmed cases, researchers at Boston University have demonstrated that CTE is a distinct neurodegenerative disease, although it shares many features of other degenerative disorders such as Alzheimer’s disease and Parkinsons. Specifically, CTE is a tauopathy, an affliction recognizable by high levels of tau proteins and loss of volume in the brains of those affected. CTE is characterized by a progressive deterioration in mental capabilities, beginning with mild memory loss and lessened concentration, and progressing to initial symptoms of Parkinsons disease to full‐blown dementia and speech abnormalities [1].

Most ex‐football players exhibiting similar symptoms in the past have been diagnosed with either Alzheimer’s disease or Parkinsons, complicating the efforts to establish CTE as a unique disease suffered mainly by professional contact sports, like boxing and football. A study published in September 2010 presented the first pathological evidence that repetitive head trauma in sports is associated with protein markers and other pathological evidence that contributes to symptoms like memory loss and decreased brain function [2]. These symptoms, in turn, often lead to a mistaken diagnosis of ALS, or Lou Gehrig’s disease.

Studies on boxing demonstrate that risk factors for CTE include the length of a boxing career, sparring exposure, and the amount of bouts a boxer participates in: all risk factors that can easily be extrapolated to football careers [3]. While repetitive head trauma is one indicator of later functional problems, one academic paper has suggested a genetic component as well. A later study focused on athletes grouped active professional athletes by age and then categorized subgroups by APOE‐ε4 carriers; the APOE‐ε4 genotype has been studied previously for its links to Alzheimer’s disease and atherosclerosis. Those in the elder group that possessed the APOE genotype exhibited significantly poorer cognitive performance than both the elder group and the younger group without the APOE genotype, suggesting that sustained head trauma may have a greater impact on those with genetic vulnerabilities [4].

Research into the link between CTE and football careers is very recent mainly because any prior studies were primarily funded by the NFL rather than credible independent sources. But what rare independent research exists has uncovered interesting correlations. A study of college football players showed that the existence of a prior history of concussion resulted in lower cognitive function [5]. Another survey of 1,090 retired professional football players reported that symptoms consistent with CTE correlated with players’ reported concussions during their career [6]. While no study has conclusively determined that CTE is caused by repetitive head trauma and concussions, the correlative evidence has been accumulating over the past few years, slowed by the under‐reporting of concussions in sports and the difficulty of diagnosing CTE in living subjects.

These few studies on football players’ health that have been published over the past three years have generated an enormous amount of both political and public interest. Press coverage has spread from more general‐interest papers like The New York Times to sports outlets like ESPN and even men’s magazines like Esquire. Even magazines with a primary audience of football fans, like Sports Illustrated, have run cover stories questioning “the hits that are changing football” [7]. On the political front, the House of Representatives’ Judiciary Committee has to date held two informational hearings on the legal issues relating to football head injuries. Despite the neutral objectives of these hearings, the NFL’s disability board structure and stance towards players’ health issues came under heavy criticism both from congressional representatives and those called to testify. Kyle Turley, a former NFL player, alleged that “the negligence of the NFL medical staff is fairly universal, [and] its effects are perpetuated and magnified by the NFL disability committees, the protection they enjoy under the collective bargaining agreement comprised of the owners and players’ union representatives which continually deny retired players disability claims wrongfully” [8]. In the same hearing, Dr. Ann McKee, co‐director of Boston University’s Center for the Study of Traumatic Encephalopathy, stated that the elevated tau levels and other indications of degeneration “are dramatically not normal‐ there is no way these pathological changes represent a variation in normal that we find under a bell shaped curve” [8]. She went on to compare the problem with the history of cigarette smoking and its health consequences, urging the panel to take preventative action with or without the support of the NFL.

Since the House hearings, the NFL appears to have addressed some of the contentious issues surrounding football players’ health, although their long‐term commitment is still very much in flux. The NFL had already established the 88 Plan in 2007, a program that awards retirees with dementia an $88,000 yearly stipend [8]. After the hearings, NFL Commissioner Roger Goodell reorganized their disability and head trauma research board, dismissing doctors on the board with no specialization in the area, as well as releasing new informational literature for players that clearly state the risk players face from head injuries. Even more recently, in October 2010, the NFL expanded a rule that prohibited upward launch hits that occur when receivers had not had sufficient time to defend themselves; the new player penalties punish those hits to the head with fines and possible suspensions [9]. But with the medical link between head trauma and CTE becoming more established, the NFL faces an uncertain future. What is their obligation to former players as they retire and face health issues?

While the NFL has taken steps to dismantle its previously hostile policies towards dementia and mental health issues, a future framework to address their players’ mental health problems is unclear. A player lockout in which players’ pay and future would be indefinitely frozen is a looming threat, pending the negotiation of a collective‐bargaining agreement between team owners and the Players’ Association by the end of the league year in March 2011. The potential lockout throws every aspect of the player‐team relationship up in the air, including teams’ responsibilities towards concussed players and ex‐players with health problems. NFL Commissioner Roger Goodell has promised that the impending lockout would not affect relations with the Players’ Association on health issues or payments through the 88 Plan [8]. At the same time, the NFL Players’ Association is responsible for representing players on a wide range of issues, and some players allege that the Association has compromised on granting retirees’ full health care compensation in order to gain ground on other player issues.

Workers’ compensation claims have been the main recourse for players seeking compensation for football‐related injuries. California law in particular stipulates that professional football players who have played in California are eligible to file a claim in California. Since any professional player that ever played at least one game in California is therefore eligible, most players seeking NFL compensation file claims in that state. In March 2010, Dr. Eleanor Perfetto filed the first dementia‐related claim, arguing that her husband Ralph Wenzel’s dementia directly stems from his seven years in the NFL. Workers’ compensation laws require documentation that the injury sustained was derived from playing football, and if the state rules in Dr. Perfetto’s favor, players will likely seek compensation through similar legal avenues [10].

While the House of Representatives has held two hearings on the issues surrounding head injuries in football, they have so far been unwilling to pass legislation specifically relating to the NFL. Legislation is pending, however, and expected to pass on regulations for concussion protection in youth sports, which will affect a much larger pool of athletes at risk and with a lower profile than professional players.

Meanwhile, the NFL, as a private business (in fact, a Congress‐mandated monopoly), is only subject to two venues of influence on responsibility for retirees: that of the law, and public opinion. Enforced legislation seems unlikely, but the visibility of football injuries has had an impact within the sport’s official organization. As sports reporters continue to ask questions about the serious, long‐term health effects of a sport meant for entertainment, fans become more aware that every Sunday they are perhaps witnessing “brain injury, involving potentially grave consequences, in real time” [11]. Perhaps more significantly, the news about brain injuries hits close to home for many fans with children; Representative John Conyers opened the House hearing on football injuries with a personal note that his 13‐year‐old son was playing a football game that very afternoon [8]. The decisions made at a professional level extend beyond the 10,000 retirees and 1,600 active players of the NFL to the millions in youth sports across the country

More than anything else, it could be the growing uneasiness of its fans that pushes the NFL to move from instituting more penalties during the game to creating a comprehensive framework for players’ health once they leave the game. In the meantime, research continues to accumulate and moves closer to establishing a definitive truth, as football players continue to run onto the field every Sunday.

References

1. McKee, Ann, et. al. Chronic Traumatic Encephalopathy in Athletes: Progressive Tauopathy After Repetitive Head Injury. Journal of Neuropathology and Experimental Neurology 2009; 68(7); 709‐735.

2. McKee, et al. TDP‐43 Proteinopathy and Motor Neuron Disease in Chronic Traumatic Encephalopathy. Journal of Neuropathology and Experimental Neurology 2010; 69(9); 918‐ 929.

3. Rabadi, Meheroz H, et. al. The Cumulative Effect of Repetitive Concussion in Sports. Clinical Journal of Sports Medicine 2001; 11(3); 194‐198.

4. Kutner, KC, et al. Lower cognitive performance of older football players possessing apoliprotein E e4. Neurosurgery 2000; 47(3); 651‐658.

5. Collins, MW, et al. Relationship between concussion and neuropsychological performance in college football players. Journal of the American Medical Association 1999; 282(10); 964‐ 970.

6. Jordan BD, et al. Association between Recurrent Concussion and Late‐Life Cognitive Impairment in Retired Professional Football Players. Neurosurgery 2005; 57(4); 719‐726.

7. King, Peter. Concussions: The hits that are changing football. Sports Illustrated, November 1, 2010.

8. House of Representatives Committee on the Judiciary hearing, Legal Issues Relating to Football Head Injuries (Part I and II). Serial no. 111‐82, 425.

9. NFL Total Access. Competition committee speaks. http://www.nfl.com/videos/nfl‐ network‐total‐access/09000d5d81b7cacb/NFL‐s‐stance‐on‐helmet‐to‐helmet‐hits

10. Schwarz, Alan. Case Will Test N.F.L. Teams’ Liability in Dementia. New York Times, April 5, 2010. A1.

11. Sokolove, Michael. Should You Watch Football? New York Times, October 23, 2010. WK1.

This article was originally published in The Science in Society Review at The University of Chicago by The Triple Helix Inc. Follow The Triple Helix Online on Twitter and join us on Facebook

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