Commentary

I
Concussions in football

n the National Football League, players are generally not considered real men un less they shrug off injuries and play on. As common and even understandable as it is, this attitude has undesirable consequences when the brain is injured. A hearing before the U.S. Congress in October 2009 called attention to the longterm effects of head injury in profes sional footballand by extension provided cautions worth heeding by the parents of foot ball players as young as age 6. At issue is the growing awareness that re peated blows to the head, not just those that are severe enough to cause concussion, increase the risk for a variety of symptoms later in life, such as depression, poor motivation and concentra tion, and problems with learning and memory. Consider what happens to the brain on im pact. It accelerates very quickly, then deceler ates just as quickly as it bangs into the skull. Nerve cells get stretched, connections between nerve cells get disrupted or sheared. Neurolo gists dispute the definition of a concussion, but terminology aside, all of this causes a short term disturbance in brain function. Its no wonder that victims feel dazed, assuming they remain conscious. But there is growing evidence that profes sional football players are prone to the kind of brain damage common in boxers, a condi tion that used to be called dementia pugilis tica, but is now referred to as chronic traumatic encephalopathy (CTE). Postmortem analyses of the brains of players who died relatively young have revealed signs of neurodegeneration simi lar to that found in Alzheimers disease. More recently, researchers have focused attention on the effect of repetitive impacts, which are common in football. One concern is that of secondimpact syndrome. If two head injuries occur in relatively rapid succes sion, such as within the course of one game, the outcome can be catastrophic, with brain swell ing and death. So players are at great risk if they return to the field too soon. But perhaps just as worrisome as serial con

cussions (however they are defined) is the sum of smaller impacts over time. The typical foot ball playerover the course of a high school, college, and pro careerwill encounter thou sands, if not tens of thousands, of hits to the head. Many experts now believe this increases the risk of CTE. NFL leaders have not been quick to endorse the idea that employment as a player is a risk factor for chronic brain disease. Of course, everyone involved in the sport knows that it is violent. It is not clear what part of the respon sibility for managing risk of injury falls to own ers and what portion to players. Pros who play at a high level accept the dan gers and hard work, while also enjoying the games challenges and rewards. In fact, many players and commentators openly disdain rules that soften the game. Thus, longterm risks usually dont become salient to the players until long after theyve retired. They are more focused on the thousands of hours of work they have invested to attain their position than on the number of head bumps theyve received along the way. It is probably impossible to walk away from the rewards of playing at a high level. NFL commissioner Roger Goodell explained to members of Congress that football is the most popular spectator sport in the United States and that more than four million children play for their school teams. Almost 100 million people watch the Super Bowl each year. This puts NFL leadership in a powerfully influential position. By establishing safety guidelines that no doubt would be emulated by youth programs, NFL leaders could protect the brain health of count less children and young adults. They should delight in the pleasure of making such an enor mous contribution to the public health. Real men would grab that opportunity and run with it.

Michael Craig Miller, M.D. Editor in Chief

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