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Concussions: The Bane of America’s Game

Aleksandra Recupero

At the start of the 2017 high school, college, and NFL football seasons more than a million suit up to play American football. It is clear that despite the 2005 discovery of chronic traumatic encephalopathy (CTE) among football players, football has yet to suffer a significant decrease in participants. The discipline, teamwork, and leadership taught to football players remains a strong attracting force for the sport. However, in 2012, the suicide of the great San Diego Charger Junior Seau was attribute to CTE and thus reignited concern for brain injuries in football.1 As every hit to the head is looked upon with greater worry and fear, the future of football is highly dependent upon new research and technology focused on protecting the players.

The prevalence of CTE among deceased NFL players, an alarming 99% in a recent study, has incited much discussion regarding head injuries in football.2 Chronic traumatic encephalopathy is a neurodegenerative disease characterized by hyperphosphorylated tau in neurons. Tau is a microtubule stabilizing protein along axons, and upon its phosphorylation, tau dissociates from microtubules. This destabilization of axonal microtubule is characteristic of many brain pathologies. Since CTE has been associated with repetitive impacts to the head, football players are at higher risk for the disease given the contact-intensive nature of football. The most significant symptoms of CTE include depression, mood changes, and dementia. In addition, at this point, CTE can only be diagnosed after death through analysis of brain tissue samples for tau tangles.3 Due to the difficulties of diagnosing CTE, making treatment nearly impossible, much attention has gone into reducing head impacts in football.

One strategy to reduce head-to-head collisions includes enacting penalties for heavy hits. In 2013, following Seau’s death and the consequent concern about CTE, the NFL enacted fifteen yard penalties for these head-to-head collisions, even threatening players with ejection from the game and additional fines.4 The NFL has also sought to strengthen their concussion protocol in order to protect players. During the preseason, players are required to be educated on concussions and concussion symptoms. The players must take neurological exams and a baseline concussion test to aid in the detection and thus diagnosis of concussions. In addition, the NFL has assigned unaffiliated neurotrauma consultants to teams with the goal of impartially assessing possibly concussed players.5 Despite such regulations, much of the responsibility lies upon the players. Besides the explicit visible signs of concussions including but not limited to loss of consciousness, loss of balance, and loss of orientation, other symptoms such as headaches and nausea can more easily be hidden, especially among athletes unwilling to step out of an important game.

Due to the numerous complications in diagnosing players, new technologies are continuously developed in the hope of improving doctors’ abilities to objectively diagnose concussions. The Brain Network Activation score was tested as a new means to diagnose concussions and to determine whether concussed athletes can return to play. The diagnostic tool assesses the person’s ability to use multiple regions of the brain to complete a cognitive task by monitoring electrophysiological data as the subject completes a task. The subject was tasked with responding to a noise that only occurred ten percent of the time while ignoring the more frequent noises. This type of test was recently shown to be inefficient due to its inability of differentiating cognitive results pre-injury and post-injury.6 The failure of such a clinical trial is indicative of the difficulty both in diagnosing concussions and developing the advancements necessary to better assess concussions.

If diagnosing concussions was not hard enough, a great deal of controversy also surrounds which factors cause the most harm to the brain in football. The long-term consequences of even sub-concussive hits have been called into question. Statistically significant changes were seen in different MRI measures for players with a large number of impacts of forces greater than or equal to 80G. Exposure measures, which are often linked to concussions, changed over the course of a season for asymptomatic athletes, implying possible long-term risks for players who did not even sustain concussions. Such players lacked changes in measurements related to gray and white matter integrity, which can be used as a measurement for axonal injury.

However, changes were observed among measures of whole-brain resting-state functional connectivity, cerebral blood flow, and neurovascular integrity. The strength and nature of connections to the cingulate cortex and the left hippocampus changed over the course of the season. An increase in cerebral blood flow was seen in the cortex, and the magnitude of the increase was associated with the number of high-G impacts. Such a change is proposed to be an adaptive response of the brain to changes in metabolic demand caused by high-impact hits. Finally, a decrease in susceptibility weighted imaging signal intensity was seen for six of eighteen players tested in this study. The six athletes had impact histories with more exposure to higher force impacts. This observed decrease in SWI signal is indicative of the accumulation of blood outside the vasculature. This link suggest that these athletes suffered microhemorrhages.7 This study illustrates that pathophysiological changes in the brain can occur merely due to repetitive impacts even among asymptomatic players.

The fact that repetitive high-impact hits may cause long-term changes to brain integrity feeds into the marketing campaign for the new VICIS ZERO1 football helmet aimed at reducing impact force. The VICIS ZERO1 scored best in the 2017 NFL/NFLPA helmet laboratory test. The helmet utilizes a soft shell and inner columns that deforms in order to mitigate force. In laboratory tests, the helmet has been found to reduce the force of impact.8 However, the helmet’s effect on concussion rates and brain integrity will only be determined with the implementation of the helmet in actual games. With many college football programs as well as select NFL players adopting these helmets, many are hopeful that the helmet has the potential to prevent concussions. For the future of America’s Game, America should certainly support and hope for the success of this helmet.

References

  1. Fainaru-Wada, Mark et al. 2013. “Doctors: Junior Seau’s Brain Had CTE.” Accessed September 18. http://www.espn.com/espn/otl/story/_/id/8830344/study-junior-seau-brain-shows-chronic-brain-damage-found-other-nfl-football-players.
  2. Mez, Jesse et al. 2017. “Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football.” JAMA 318(4):360-370. 
  3. Cherry, John et al. 2016. “Microglial neuroinflammation contributes to tau accumulation in chronic traumatic encephalopathy. ” Acta Neuropathologica Communications 4, 112. 
  4. NFL Football Operations. 2017. “NFL Video Rulebook Rule 12 Section 2 Article 7 Defenseless Player.” Accessed September 18. http://operations.nfl.com/the-rules/nfl-video-rulebook/defenseless-player/
  5. NFL Head, Neck and Spine Committee. 2017. “NFL Head, Neck and Spine Committee’s Concussion Diagnosis and Management Protocol.” Accessed September 18. https://www.playsmartplaysafe.com/focus-on-safety/protecting-players/nfl-head-neck-spine-committees-protocols-regarding-diagnosis-management-concussion/
  6. Broglio, Steven et al. 2017. “Brain Network Activation Technology Does Not Assist with Concussion Diagnosis and Return to Play in Football Athletes.” Frontiers in Neurology 8, 252.
  7. Slobounov, Semyon et al. 2017. “The effect of repetitive subconcussive collisions on brain integrity in collegiate football players over a single football season: A multi-modal neuroimaging study.” NeuroImage: Clinical 14, 708-718.
  8. VICIS. 2017. “2018 VICIS ZERO1.” Accessed September 18. https://shop.vicis.co/products/zero1

Aleksandra Recupero is a second-year student at the University of Chicago majoring in Biological Sciences. Her interests include medicine and neuroscience research.

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