What the NFL Can Do to Survive Its Concussion Epidemic
Five high school football players have died this year from head injuries. Researchers have found a degenerative brain disease linked to repetitive trauma, chronic traumatic encephalopathy, in the brains of more than 100 deceased former NFL players. As popular as the NFL might be, this crisis is shaking its foundations: the parents of youth players. In April, a Harris Poll of 2,012 adult Americans found that 89 percent believed concussions were a moderate to severe health concern, and 25 percent would not let their children play some contact sports because of a fear of concussion. So if football is going to exist in 50 years time, the sport is going to need to solve the problem of brain trauma.
History, though, offers football fans a glimmer of hope. In the 1900s, football survived an equivalent existential crisis. Players were being crushed and were dying from head trauma. On the East Coast, Columbia abolished football and Harvard threatened to do the same. On the West Coast, UC Berkeley and Stanford switched out football for rugby. But radical changes in rules and tactics—including the forward pass—saved the game. And less than two decades later the NFL was born.
So can football solve concussions? Not exactly. “Concussions have been around for a long time, since the stone age, probably,” says Alvaro Pascual-Leone, a neurologist at Harvard Medical School and associate director of Harvard’s Football Players Health Study. “There’s nothing new about concussion.” The injury is a natural consequence of impact, and as long as football remains a contact sport, players will still suffer concussions.
However, the league could reduce the incidence of concussion, particularly by limiting exposure. New rules could ban plays that routinely put players at greater risk of head injury, or eliminate contact in practice. A game situation is always going to be higher risk than training, but, says Bill Meehan, director of the Micheli Center for Sports Injury Prevention and an associate director of the football health study, “I don’t have to practice hitting my head against a wall.”
According to Meehan, better enforcement of existing rules would help, too. “There is a rule in the books that a referee can throw somebody out of the game [for illegal hits],” he says. “Now, I’ve been watching football my whole life. I’ve never seen someone thrown out of the game. Rugby, soccer, ice hockey, I see it all the time.”
Even something as simple as limiting maximum player weight would be a simple—albeit extreme—way to reduce impact forces, says Uzma Samadani, a neurosurgeon at the University of Minnesota. “These players are getting bigger and stronger, bigger and stronger, year after year, and at some point it’s going to reach the point where they’re capable of killing each other,” she says. Samadani works as a neurotrauma consultant for the NFL and was on the sidelines in Minnesota this season when Chiefs wide receiver Jeremy Maclin suffered a concussion. As Vikings cornerback Captain Munnerlyn wrapped up the Kansas City player, Maclin’s helmet took the brunt of the force of their combined weight of 382 pounds hitting the turf.
The problem is, all these proposals for changes may be getting out ahead of the science. Micky Collins, director of the University of Pittsburgh Medical Center Sports Medicine Concussion Program, says that making major changes on the basis of incomplete information might have serious and unintended consequences. Take, for example, pitch counts and ulnar collateral ligament injuries in baseball. Pitch counts are supposed to reduce wear and tear on pitchers, but whether or not they actually do remains controversial.
For players, though, even the possibility of danger is worrisome. Two decades ago, “you knew about concussion. It was something you got dizzy from, and that was it,” says Max Lane, an offensive tackle who played seven seasons with the Patriots from 1994 to 2000. “And now, knowing everything, it is scary for the future.” Lane never had a diagnosed concussion, but is unsure of the long-term effects of the blows he did receive.
Linebacker Isaiah Kacyvenski was drafted by the Seahawks out of Harvard in 2000 and played seven years in the NFL before returning to his alma mater for business school. “So I had this before and after snapshot around the ability to be able to think through complex solutions,” Kacyvenski says. “I’d be lying to you if I was to say there was not a difference before and after.”
Cognitive problems can have many causes, but “if you were in the NFL, automatically you attribute that to being in the NFL.” Meehan says. Niners rising star Chris Borland was the most public casualty of the paranoia around head trauma. The linebacker quit football earlier this year, citing fears over the consequences of repetitive head impact.
The most dangerous conclusion could be questioning the use of the helmet. While football’s most iconic piece of protective gear might actually have increased the incidence of concussions by converting focal, skull-fracturing hits into diffuse, brain-rattling ones, it has almost certainly saved lives. But more than that, the helmet offers solutions to football that rugby, in comparison, doesn’t have. First, improvements in helmet construction, including padding that hardens on impact and honeycomb structures only possible through 3D printing, may help absorb forces. Second, the helmet provides a perfect way to wrap each player’s brain in sensors such as accelerometers, and to track exactly what happens during a game. “Perhaps we’ll even have EEG built in,” Samadani says, “so you can do quantitative EEG in real time and know when you have dysfunction immediately.” Or even monitor how the brain actually moves within the skull using a system that shines near-infrared light through a player’s head—that’s being developed by Gary Strangman, a psychiatrist at Harvard Medical School.
With all of those sensors, in 50 years time, “we’ll have a completely different way to diagnose [concussion],” Samadani says. “Concussion will be like a heart attack.”
Perhaps that analogy extends beyond detection. Doctors can restart hearts with electrical shocks, and far less powerful electrical pulses can help regulate and reset an injured brain. Exercise benefits those with heart disease and can speed up recovery, and mental exercises can help a brain recover from concussion. And drugs could play a crucial role in both, too. Kun Ping Lu, a professor of medicine at Beth Israel Deaconess Medical Center, and his wife, Xiao Zhen Zhou, an associate professor of medicine, are researching an antibody that binds to cis phosphorylated tau protein. In studies on mice, they have shown that the concentration of this protein rises significantly after head impact, and that it may be responsible for developing CTE-like pathologies.
This antibody could be used to detect cis P-tau in a blood test, helping to diagnose a concussion, and even to clear the protein from an injured player’s body. “There will come some [sideline] therapy in the next five to 10 years,” Lu says. “People take a medicine and at least stop some damage, prevent some long term consequences.”
But if concussion becomes comparable to a heart attack, by Super Bowl 100, could we perhaps be able to transplant irreparable brains, copying the part that is you as if it was software? Unfortunately not. “These highly ambitious brain mapping projects, I think they’re extremely important,” says David Putrino, director of telemedicine and virtual rehabilitation at the Burke Rehabilitation Center in White Plains, NY. “But we have mapped every single neuron, every single connection, every single thing that we can know about a brain, in a C. elegans worm, but we still can’t predict the way the connections are going to work and how it does what it does. We still don’t know how it’s being it.”
Fifty years is just too soon for science fiction.