Every autumn weekend in the US, thousands of youngsters as young as 5 years old strap on their pads, lace up their cleats and get after each other on the football field.
However, fewer and fewer of them are playing tackle football. Parents are concerned about concussions, brain injuries and brain damage.
Proponents of the sport say there’s little to worry about, and point to improvements in helmets, shoulder pads and other equipment, as well as improvements in concussion diagnosis and treatment.
The National Football League has spent millions of dollars trying to mitigate the risk of concussions and concussion-related problems. Football organizations at all levels are educating players, parents and coaches about preventing concussions or minimizing their impact should they occur. Academia is researching concussions and concussion-related problems with a real sense of urgency. Equipment manufacturers are producing new and better equipment to reduce the likelihood and frequency of concussions on what seems like a daily basis.
It’s clear that there is an “all hands on deck” campaign to figure out the concussion problem in American football (and in other sports, too.)
But what if all these advocates, coaches, educators, researchers, parents and manufacturers are missing the point? What if concussions are just the tip of the iceberg as it relates to the brain damage that football can inflict on players?
Unfortunately, that’s petty much the way it’s starting to look. As the research continues into how tackle football affects brain health, we’re learning that chronic traumatic encephalopathy, or CTE, a condition associated with concussions, isn’t the only brain damage we need to concern ourselves with in relation to tackle football.
In case you’ve been living under a rock for the last 10 years, CTE is a neurodegenerative disease. It was originally believed to occur only to people who’d suffered multiple head injuries. More recent research has indicated that CTE may occur in those who’ve had multiple head strikes, even if no injury was reported or noted. (1)
Dr. Lee Goldstein, associate professor of psychiatry at Boston University and co-author of a groundbreaking study on head impact, brain trauma, concussions and CTE, said “It’s the hits to the head, not concussion, that trigger CTE.”
CTE is a serious and often deadly condition. Football fans know the stories of Junior Seau, Jovan Belcher and Aaron Hernandez, all of whom have been confirmed as having had CTE. In one Boston University study, CTE was present in the brains of 90 out of 94 deceased former NFL players. Additionally, hundreds of living, retired NFL players have been diagnosed with symptoms of CTE or ALS (Lou Gehrig’s Disease.) Included in this group are such well-known names as Brett Favre, Tony Dorsett and Jim McMahon.
Some of the players, alive or dead, who have been diagnosed never reported or were diagnosed with a concussion. This lends credibility to the idea that repeated subconcussive head contacts are the real underlying cause of CTE.
Think of it this way. If you take a wooden mallet, like the ones used for cracking crabs, and begin tapping lightly on the side of a glass, you probably won’t break anything. But over time, the glass will weaken and eventually, the structure may become so weak that it breaks without being hit. The human brain is like the glass, subconcussive hits are like the mallet. No obvious damage from each hit, but over time…
This is exactly what recent research is telling us. In a study presented at its 2018 annual meeting, the Radiological Society of North America concluded that a single season of youth tackle football may result in disrupted brain development for athletes aged 8 to 13 years old. (2)
Researchers used a HIT system (Head Impact Telemetry System,) which employs helmets lined with accelerometers and sensors that measure the magnitude, location and direction of impacts to the head. They established a preseason baseline for each player in the study using a functional MRI (fMRI) test. Post-season tests revealed something disturbing.
Regardless of concussion risk or reporting, players exhibited a significant reduction in grey matter pruning in the default mode network, a series of structures deep within the grey matter areas of the brain involved in higher cognitive functions, such as planning and controlling social behaviors.
“Disruption in normal pruning has been shown to be related to weaker connections between different parts of the brain,” said Gowtham Krishnan Murugesan, M.S., research assistant in the Department of Radiology at UT Southwestern Medical Center in Dallas, Texas. “Our study has found a significant decrease in gray matter pruning in the frontal default mode network. Pruning is an essential part of brain development. By getting rid of the synapses that are no longer used, the brain becomes more efficient with aging.”
At Wake Forest University, researchers found evidence of damage to white matter tracts, bundles of nerve fibers that carry signals between parts of the brain. In particular, they noted degenerations, swelling and contraction in the corpus callosum, a critically important band of nerve fibers that connects the right and left hemispheres of the brain. The corpus callosum integrates cognitive, sensory and motor functions between the two sides of the brain.
None of the players involved, all 9 to 12 years old, had reported a concussion previously. The hits they took were all subconcussive, therefore. “The years from age 9 to 12 are very important when it comes to brain development,” said study lead author Jeongchul Kim, Ph.D., from Wake Forest School of Medicine in Winston-Salem, N.C. “The functional regions of the brain are starting to integrate with one another, and players exposed to repetitive brain injuries, even if the amount of impact is small, could be at risk.” (3)
In another shocking study, neuropathologist Dr. Ann McKee and her team went looking for tau proteins in 211 deceased football players who’d been diagnosed with CTE. Tau proteins are associated with CTE and kill brain cells. Her expectation was that she would find lots of tau proteins in the players who started playing the game at a young age. Surprisingly, age of playing onset didn’t correlate with tau protein levels, meaning the length of time playing didn’t necessarily influence the severity of CTE.
What she discovered, however, should concern players and parents everywhere. The players who started playing as children suffered symptoms of brain damage and disease earlier in their lives than those who started later in life.
84 of the 211 players whose brains were studied began playing before age 12. Every one of them had suffered cognitive, mood and behavior symptoms by age 13! In fact, comparatively, each one year earlier a player started playing football predicted earlier onset of cognitive, mood and behavioral problems by 2.44 years! (4)
“It’s as though the brain of these people who started playing early football was less resilient to pathology,” says McKee, chief of neuropathology at Boston VA Healthcare System, and director of Boston University’s CTE Center. “It’s sort of like they have a weakened nervous system, and set you up for earlier onset of any of these disorders. That was a surprising finding.”
35 players brains did not have CTE. However, those who started playing before age 12 had onset of cognitive symptoms by an average of 20 years. Mood and behavior symptoms kicked in an average of 22 years earlier. Equally as disturbing was the revelation that 26 of those 35 had other neuropathological problems like axonal injuries, frontotemporal lobe degeneration, Alzheimer’s and Lewy body pathology. You may recall that Robin Williams died of Lewy Body Dementia.
Lewy bodies are microscopic proteins that develop in the brain and lead to cognitive dysfunction, mood changes, sleep disorders, dementia and eventually, movement disorders and a kind of paralysis. It’s the 2nd most common form of dementia, behind Alzheimer’s.
Even if the risk of concussion was eliminated from tackle football, other and arguably more serious risks still remain. It seems virtually impossible to remove subconcussive impacts from the game. The very fabric of football is contact and is what attracts many fans and players alike to it. But the reality remains: kids brains are at risk in tackle football.
So what should be done? In 2015, the American Academy of Pediatrics issued a paper called “Tackling in Youth Football.” In it they had the following recommendations:
- Officials and coaches must enforce the rules of proper tackling, including zero tolerance for illegal, head-first hits;
- Players must decide whether the benefits of playing outweigh the risks of possible injury;
- Non-tackling leagues should be expanded so athletes can choose to participate without the injury risks associated with tackling;
- Skilled athletic trainers should be available on the sidelines, as evidence shows they can reduce the number of injuries for players.
They also addressed the oft-suggested idea of delaying the introduction of tackling until athletes are older and, according to some, better able to absorb contact. The AAP recognized the obvious paradox:
“Delaying the introduction of tackling until a certain age may reduce the risk of injury for ages when tackling is prohibited, but this could lead to even higher rates of injury when tackling is later introduced if players have their first tackling experiences when they are older, stronger and bigger, according to the AAP.”
The NFL has gone to a practice schedule which reduces the frequency of contact during practices. The obvious problem with this at the youth level is that it is at that level that children are learning to hit and be hit. The players in the NFL are expert at this already, hence their professional status.
New York, New Jersey, California and Illinois have all had bills introduced in their legislatures banning tackle football in some way in those states. The most popular version of this idea would ban children under 12 from playing tackle football. This may or may not be the answer. Most likely, it isn’t.
Here’s a few things you can do to minimize your risk of concussion:
- Ensure that playing surfaces are well-maintained and don’t contain holes or divots in the ground that could cause athletes to fall or trip.
- Ensure that all equipment, including helmets and padding, fits properly.
- Understand that children are different than adults and are constantly growing and changing. Recognize that strength and control of the head improves as children develop.
- Get your players some real core training. Not abs, not sit-ups, real core training that includes reactive core strength and anti-rotation training. The core supports the spine, which supports the neck, skull and by extension the brain. Get it strong!
- Strengthen the neck. According to one study, for every pound of increased neck strength, concussion risk is reduced by 5%. (5)
For me personally, the idea that tackle football would ever go away because of the risk of debilitating brain injury and damage is not a happy prospect. However, we each get just one brain, and we can’t live without it. So my hope is that we find a way to minimize the dangers so we can all enjoy the game with a lot less fear.
Keep the faith and keep after it!
- McKee, A., Goldstein, L., et al., Concussion, microvascular injury, and early tauopathy in young athletes after impact head injury and an impact concussion mouse model, Brain, February 2018
- Murugesan, G., et al., Intra-Default Mode Network Connectivity Changes from a Single Season of Youth Football Distinguish Levels of Head Impact Exposure, RSNA Annual Meeting
- Kim, J., et al., Subconcussive Head Impact Exposure and White Matter Tract Changes over a Single Season of Youth Football, Radiology, October 2016
- McKee, A., et al., Age of first exposure to tackle football and chronic traumatic encephalopathy, Annals of Neurology, April 2018
- Collins, CL., et al., Neck strength: a protective factor reducing risk for concussion in high school sports, Journal of Primary Prevention, October 2014