Head Injuries and Football: A Crisis Too Long Ignored?

From the marquee names of the National Football League to the hundreds of college programs to the thousands of high school teams, football has carved a special place in America's psyche. This rests not only on its entertainment value — for a great many boys and men, football has taught the values of teamwork, discipline and sheer grit. But it is a sport with a significant risk of injury, and recent months have seen growing concern about a not immediately obvious, but particularly upsetting, kind of health threat: delayed brain damage from repeated concussions. In "Head Injuries and Football: A Crisis Too Long Ignored?" Today's Science takes an in-depth look at this problem, and how scientists and the public at large are responding to it.
In the macho, rough-and-tumble culture of the National Football League (NFL), injuries are accepted as an unfortunate but inevitable reality. Every NFL player endures bumps and bruises, cuts and contusions, and minor sprains and strains as the uncomfortable price of fame and fortune. Of course, some injuries are too debilitating to be considered routine. Broken and dislocated bones, severe sprains, and torn muscles, ligaments, or tendons force even the toughest players to miss multiple games, or even whole seasons.


Concussions are special; they are invisible and, in many instances, the immediate symptoms last only minutes. A concussion occurs when the brain is jarred inside the skull. A concussed person may lose consciousness for a brief period, and then will be disoriented for a while. Not long ago, a concussed NFL player would get a whiff of smelling salts to clear his head a bit and then eagerly get back into the game. It was a matter of showing his toughness.
In response to growing concerns about concussions, the NFL in 2007 instituted new rules and directives. Now, a player who suffers head trauma cannot return to action in the game in which the injury occurred. After the game, he is required to undergo a thorough battery of tests by his team's medical staff, and he cannot again practice or play until cleared to do so by the doctors. The NFL also banned intentional helmet-to-helmet contact, a cause of head injuries.
So, you ask, how often do concussions occur in the NFL these days? Well, no fewer than five players were concussed in regular-season games in October 2009: San Francisco 49ers linebacker Jeff Ulbrich on October 4, San Francisco safety Michael Lewis on October 11, Tampa Bay Buccaneers punt returner Clifton Smith and Buffalo Bills quarterback Trent Edwards on October 18, and Philadelphia Eagles running back Brian Westbrook on October 26. It was Lewis's third diagnosed concussion of 2009 (the two earlier ones happened during the summer preseason). Ulbrich is a 10-year NFL veteran with a double-digit history of concussions. When his latest head injury failed to respond to medical treatments, the 49ers in mid-October placed Ulbrich on injured reserve, meaning he would have to sit out the rest of the season.


An isolated concussion may be bothersome, but it is the cumulative effects of multiple concussions that are the focus of present concern — there are indications that these effects may be much more incapacitating and dangerous than anyone imagined. Medical specialists at Boston University recently have linked repetitive football head injuries to chronic traumatic encephalopathy, a degenerative brain disease characterized by dementia and, in some cases, suicidal depression. And, the scientists have found that the potential risks are not limited to pro players. The findings — contained in a paper published in the July 2009 issue of the Journal of Neuropathology and Experimental Neurology and described in press reports — have created a firestorm of controversy. The subject has even attracted the attention of a U.S. congressional committee. [See NFL Head Injuries, December 18, 2009]

A Survey Raises Questions

The latest controversy over concussions was triggered by a confidential telephone health survey of some NFL retired players commissioned by the league itself. The NFL did not make the poll public, but some elements apparently were leaked to New York Times reporter Alan Schwarz, who reported the findings on September 30, 2009. Over the past few years, Schwarz has published several articles in the Times on the lingering effects of football head injuries.
The league commissioned the poll to gather information in preparation for negotiations on a new Collective Bargaining Agreement with the players' union, the National Football League Players Association (NFLPA). The health benefits of retirees would be among the matters to be negotiated.
The survey was conducted by the Survey Research Center of the University of Michigan, in Ann Arbor. The center asked 1,063 retired NFL players a series of questions on a wide range of personal health issues. One question, paraphrased by Schwarz in the Times, was whether a player had been diagnosed with "dementia, Alzheimer's disease, or [another] memory-related disease" since retirement from football. According to the Times, some 6.1% of the respondents aged 50 and older, and 1.9% of the respondents aged 30-49, reported that they had received dementia-related diagnoses. Based on federal health statistics, the rate among the older respondents was five times higher than the national average for dementia, and the rate among the younger respondents was 19 times the national average. (Subsequent news stories revealed that the total number of respondents who answered "yes" to the question was 56.)
Dementia is an irreversible, progressive deterioration of mental function marked by confusion, impaired memory, and impaired judgment. Its most common — but not sole — cause is Alzheimer's disease, a degenerative brain affliction that manifests mainly in the elderly.
Medical experts cited by the Times agreed that the survey fell short of being valid medical research. (The findings were neither peer-reviewed nor published in any reputable science journal, two hallmarks of legitimate research.) But, as Amy Borenstein, an epidemiology professor at the University of South Florida, told Schwarz: "[The dementia responses] suggest something suspicious....It's something that must be looked into with a more rigorous study."
The NFL has been reluctant to acknowledge a direct link between football head injuries and impaired mental function. In reaction to the leaking of the survey results, NFL spokesman Greg Aiello told Schwarz, "There are thousands of retired players who do not have memory problems. Memory disorders affect many people who never played football or other sports."
David Weir, the University of Michigan professor who headed the survey, pointed out in a comment reported by the Associated Press, "The study was not designed to diagnose or assess dementia. The study did not conclude that football causes dementia."

Troubled Retirements, Troubling Deaths

The survey findings nudged the national media into taking a close look at the ongoing work of the Sports Legacy Institute and its partner, the Center for the Study of Traumatic Encephalopathy (CSTE). The institute, based in Tampa, Florida, is a nonprofit organization devoted to research on sports head injuries. It was founded in 2007 by Chris Nowinski, a former Harvard University football player whose career as a professional wrestler had been cut short by repeated concussions. The CSTE, part of the Boston University School of Medicine, was formed in 2008 to study the donated brains of deceased athletes. Since 2008, Nowinski has persuaded over 100 current and retired football players, ice hockey players, and other athletes to agree to donate their brains to the CSTE upon death.
Nowinski had been inspired to form the institute after learning of the pioneering research of Bennet Omalu, a brain specialist and forensic pathologist formerly attached to the University of Pittsburgh, in Pennsylvania. Omalu became the first scientist to identify chronic traumatic encephalopathy (CTE) in football players when he biopsied the brains of three NFL retirees who had died between 2002 and 2006. All three were known to have suffered many concussions over the course of their NFL careers.
CTE, once known as "dementia pugilistica," is a degenerative brain disease originally identified in deceased "punch-drunk" boxers in 1928. In boxers, the disease is the apparent result of taking too many punches to the head. Omalu found one of the telltale signs of CTE — abnormally high concentrations of a protein called tau — in the autopsied brains of all three deceased NFL ex-players. In normal concentrations, tau is necessary for the transfer of electrochemical signals between brain cells. Repetitive concussions apparently stimulate a toxic overproduction of tau. Alzheimer's disease, too, can stimulate an overproduction of tau. But Alzheimer's brains always show abnormal clumps or lesions of beta-amyloid protein. Excess tau in the absence of amyloid lesions points to CTE, not Alzheimer's.


Overabundant tau forms bundles of brown fibrous tendrils — in medical parlance, neurofibrillary tangles and neuropil threads — that damage, and then kill, entire regions of healthy brain cells. In turn, the diseased parts of the brain cause not only dementia, but , bizarre or erratic behavior, and sometimes parkinsonism. (Parkinsonism, a brain disorder that mimics Parkinson's disease, is characterized by muscle tremors, impaired balance, and speech difficulties, among other problems.) As yet, medical science has no way of detecting tau tangles in the brain of a living person; they can only be found by autopsying the brain of a dead person.
Omalu initially joined the Sports Legacy Institute, but left the organization in 2008 over personal disagreements with Nowinski. Omalu's research was validated and advanced by the CSTE, codirected by Massachusetts neuropathologists Ann McKee and Robert Cantu. In early 2009, they reported finding tau tangles in the biopsied brains of six of seven dead former professional football players, including the same three retirees initially studied by Omalu. The lone exception was Damien Nash, a former Denver Broncos running back who had died suddenly in 2007, at the age of 24, of a previously undiagnosed heart ailment. The specialists found no evidence at all of CTE in Nash's brain.
The brains of the other six NFL ex-players were riddled with tau tangles. (Only one of the six had traces of amyloid lesions, perhaps an indication that the retiree was in the initial stages of Alzheimer's disease in addition to having CTE.) All of the ex-players had died between the ages of 36 and 50 amid troubled retirements, and none had what could be regarded as a routine death. For example, Mike Webster, a Pro Football Hall of Fame center for the Pittsburgh Steelers, struggled with depression, cognitive difficulties, and financial hardships before succumbing to heart failure at age 50 in 2002. Andre Waters, an exuberant star defensive back with the Eagles, spiraled into a deep depression during retirement and shot himself to death in 2006, at age 44. Tom McHale, a Tampa Bay offensive lineman turned respected businessman, sank into alcoholism and drug addiction. In 2008, at age 45, McHale overdosed on a fatal combination of cocaine and prescription painkillers.


The CSTE also announced that it had found evidence of CTE in the brain of a deceased 18-year-old who had played high school football. (The youth's identity and cause of death were withheld from the public at the request of his family.) Later in the year, the neuropathologists reported that Mike Borich, a deceased former college football player and honored college coach who never played pro football, had CTE. (Borich, 42, died of a drug overdose in February 2009.) The implication of those announcements — that high school and college athletes could develop CTE — stirred nationwide concern.
The center published a summary of its CTE research in a paper in the July 2009 issue of the Journal of Neuropathology and Experimental Neurology, with Ann McKee as the lead author.

Congress Weighs In

The Judiciary Committee of the U.S. House of Representatives held a hearing on the issue of football head injuries on October 28, 2009, in Washington, D.C. The committee's chairman, John Conyers, a Democrat from Michigan, called the issue a matter of "life and death." He elaborated: "I say this not simply because of the impact of these injuries on the 2,000 current players and more than 10,000 retirees associated with the NFL . . . . I say it because of the effect on the millions of players at the college, high school, and youth levels."

 NFL Commissioner Roger Goodell testified before the committee. Under questioning, he declined to acknowledge a connection between concussions and brain disorders. Goodell contended that the league was willing to take unspecified new steps to make NFL games safer, and to improve disability benefits for retirees. He alluded to a current benefit, the "88 Plan," which now provides up to $88,000 a year to any retiree with diagnosed dementia, regardless of the cause. He also disclosed that a panel of NFL medical experts was preparing a detailed study on head trauma.


Robert Cantu, codirector of the Center for the Study of Traumatic Encephalopathy, told the committee that there was "growing and convincing evidence" that repetitive concussions cause irreversible brain damage. "The public health risk is already here, and we cannot afford to wait any longer to make changes to the way we play sports."
The committee's ranking Republican, Lamar Smith of Texas, argued that Congress should stay out of the matter. "Football, like soccer, rugby, and even basketball and baseball, involves contact that can produce injuries," he noted. "We cannot legislate the elimination of injuries from the games without eliminating the games themselves."

Discussion Questions

Assuming it has the power to do so, should the federal government intervene in amateur or professional sports to reduce the risk of head injuries? If yes, what form should that intervention take? If no, explain why not.
Batting helmets were not in common use in professional baseball during the first part of the 20th century, but are now mandatory (and of course are used in Little League and other youth leagues). Can you think of other changes in the way games are played that have been introduced for safety purposes? What specific steps, if any, do you think could be taken in football to reduce the risk of concussions? Would those steps substantially affect the character of the game?

Other 

{SEE ALSO HEAD INJURIES LEADING TO MEMORY PROBLEMS IN SOCCER}