You hear about it in news stories and see it in movies: People are struggling to understand what the risk is of a concussion causing long-term brain damage. Their biggest fear is that they will develop chronic traumatic encephalopathy (CTE), which results in abnormal deposits of proteins in the brain, possibly causing a severe form of early onset dementia. Despite its discovery in 1957 by renowned neurologist Dr. Macdonald Critchley, CTE was only recently defined, diagnostically, by a U.S. National Institutes of Health (NIH)-funded committee, when the members met to spell out CTE criteria in February 2015.
Now, with the opening of the movie “Concussion,” starring Will Smith, which tells the story of Dr. Bennet Omalu, the pathologist who discovered CTE in Mike Webster and several other NFL players, more attention is being paid to the long-term risks associated with concussions . The movie is an emotional portrayal of patients with CTE, and resulted in a recent editorial by Dr. Omalu calling for a ban on football, hockey and soccer in children under the age of 18.
But is a ban for children in sports the right answer? The public response that followed Dr. Omalu’s editorial about an all-out ban has been mixed. Some people have said that they believe that this goes way too far, with potentially negative implications for a child’s social and emotional development. Other parents who are fearful of CTE have said that, until we have further information about the exact mechanisms and genetic influences that define a higher-risk profile for developing CTE, it might be safest to put such a ban in place.
Can governments legislate risk?
There are three reasons why a ban is the wrong answer. First, it’s impossible to legislate away all adolescent risk-taking behaviors. The adolescent brain is not fully myelinated — the nerves have not fully attained their coverings. Rather than sending signals through relatively few established pathways, as it does in adults, the brain tries multiple pathways. Thus, the adolescent brain has high synaptic plasticity (the ability to change direction) and is wildly creative, relative to the more inhibited, fully myelinated — and degenerating — adult brain.
Legislation won’t change this biological fact: Children are more impulsive, less restrained and more inclined to take risks. Football is on the riskier end of the spectrum of sports: In tackle football, there are about 10 deaths per million participants per year (not all due to brain trauma), but it is still less risky than equestrian sports (20 deaths per million per year) and skiing, snowboarding, skateboarding or bicycling (each with 10 to 15 deaths per million per year).
Losing more than game play
The second reason not to eliminate tackle football is that it’s not entirely clear that eliminating all risk-taking behaviors from childhood is in the interest of our society.
When they’re playing football, children learn to assess risk based not only on their own capabilities, but also on the capabilities of their teammates, who are there to protect the other members of the team and work for everyone’s interests. This capacity for rapid risk assessment and plan execution, and the reliance on teamwork and the assessment of evolving challenges may serve our children well in their later professional lives.
Without the experience of some risk in childhood, we might not have adults who engage in risk-taking behaviors — like astronauts, explorers, entrepreneurs, fire rescue personnel or surgeons, for example. In our book, “The Football Decision,” we surveyed neurosurgical department chairs and brain injury experts, and found that they are at least 16 times more likely than typical undergraduates to have played contact sports in college. They are 1.5 times more likely than the average American to have sustained a concussion. And, 83 percent of neurosurgeons would allow their own children to play contact sports.
Clearly, we do not yet understand all the risks and benefits of contact sports.
What are the true long-term effects?
The third reason to not ban kids from contact sports is that there is no substantive scientific evidence indicating that subconcussive or even concussive impacts in youth have deleterious, long-term healtheffects. Some recent studies assessing long-term risks of contact sports have questionable clinical significance.
For example, in December 2015, the Mayo Clinic issued a press release that stated that one-third of all males participating in contact sports were at risk for CTE. But let’s look a little more closely at that data: The paper by Mayo Clinic graduate student Kevin Bienieck and colleagueswas a study of male brain donors who died in their mid-70s and had developed neurodegenerative disorders in their late 60s.
The investigators determined whether the study subjects had been exposed to contact sports by looking at their medical records and searching online through their obituaries. Of the study subjects, 66 men were thought to have participated in contact sports and 198 nonparticipants were also identified. There was no difference in age between the groups with regard to the onset of neurodegenerativesymptoms.
The investigators found evidence for CTE in 21 of the 66 former athletes. Of the group of athletes with CTE, three had been diagnosed with prior concussions in their lifetime. However, in the 198 individuals whose exposure to contact sports was unknown, 33 had documented cases of head trauma.
Thus, people who had participated in sports but who did not have documented brain trauma had CTE, while people with documented brain trauma did not. The paper states, “Among those exposed to contact sports, those with CTE pathology did not differ from those without CTE pathology with respect to noted clinicopathologic features.” In other words, under the microscope, the brains of the people who were found to have the abnormal brain tangles indicating CTE had no symptoms in real life that were different from those who did not have brain tangles. The symptoms of the patients with CTE were no different from the people without CTE. The work of the Mayo Researchers was significant because they were able to demonstrate that contact sports were associated with CTE, but they were unable to show that CTE resulted in symptoms.
In that same journal, Acta Neuropathologica, where the Mayo Clinic study appeared, a second paper was published by Helen Ling of the Queen Square Brain Bank for Neurological Studies and UCL Institute of Neurology, and her colleagues. The study compared the brains of people who died with neurodegenerative diseases to control subjects. The paper found that “the prevalence of CTE in NDD [neurodegenerative diseases] (11.8 percent) was statistically the same as in controls (12.8 percent).” The study further found that the patients with CTE died at a mean age of 81 years and that “most positive cases [were] likely to be clinically asymptomatic.” Again in this study, CTE is found under the microscope in equal proportions of healthy, normal asymptomatic people as it is in people with dementia and other diseases.
This raises questions regarding the significance of the pathologic findings seen under the microscope. Does it matter if athletes are at increased risk for CTE, if the disease has no symptoms?
Caution for concussions
The vast majority of children will recover from a concussion without any adverse consequences — such as headaches, memory problems or dizziness — in seven to 10 days, with a small proportion demonstrating lingering symptoms up to 45 days after the injury.
It is important to identify those children and teens who experience prolonged symptoms after a concussion so that they may be removed from competition and engage in a short period of cognitive and academic rest, with gradual reintroduction of activities as symptoms subside. Returning to play to soon after an injury can result in increased risk for re-injury.
Gentle physical activity along with maintaining proper hydration may have a role in helping to speed symptom resolution in those with mild concussions.
In a study published in the Mayo Clinic Proceedings, clinic researcher Rodolfo Savica and his colleagues followed, for more than 50 years, high school students from Rochester, Minnesota, who played American football within a 10-year study period (1946-1956). The researchers found that the players did not have a higher incidence of neurodegenerative diseases than members of the choir, glee club or band. Additionally, epidemiological studies of people sustaining mild traumatic brain injury demonstrate no increased risk for dementia unless the injury occurs after the age of 65 years, when resilience is reduced.
More important, if we truly focus on the traditional risk factors for dementia in American society — sedentary lifestyle, high-fat diet, smoking, diabetes, high blood pressure and poor education — we might further help to reduce the large burden of those risk factors on neurodegenerative disease, which may be equally important as a causative factor in patients with neuropathologically proven cases of CTE.
Within the spectrum of brain-injury-inducing activities contemplated by the plastic and unpredictable minds of American youth, football represents an extremely tiny fraction of the range of activities where risk actually resides.
Focused efforts to eliminate football detract from the true, preventable causes of brain injury — specifically, gun violence, motor vehicle collisions and drug or alcohol abuse, according to the CDC. Such efforts also work against the elimination of the greatest scourge to the health of people in our modern society: obesity due to inactivity, which was recently reported by the CDC, along with research published in JAMA in December 2015. Both reports indicated that in 2012, nearly one-third of children in the United States were overweight, and more than half of this group was classified as obese.
The question we should be asking is not whether we should ban football, but how we can make it safer. We need to encourage more children to be active in the sport of their choice, which should be played as safely as possible.
The American Academy of Pediatrics (AAP) proposes a series of measures to make football safer, including limiting contact practices, rule changes, improved protective equipment and neck strengthening, among others. The AAP has it right — make football safer and get the kids out there playing.
Children who want to play football should be encouraged to do so, and those who do not should be counseled to seek alternative exercises that are, hopefully, at least as beneficial.
Disclosures: Dr. Uzma Samadani has served as a sideline unaffiliated neurotrauma consultant to the NFL. However, she is not authorized to speak on behalf of, or represent, the NFL in any capacity and the views expressed here are solely her own. Dr. Robert Glatter was a sideline physician for the New York Jets from 2004 to 2008, with no current relationship with the NFL or its subsidiaries.