Being an ardent football fan I was quite surprised by Chris Borland’s announcement that he would retire from the NFL. He is 24. I was still a fledgling medical student at 24.
Borland has decided to retire sooner rather than later because of a medical issue. Not a medical condition he has. But a medical condition he may acquire should he continue playing football. Borland has made a judgment call. He has decided that the risks of repeated head trauma outweigh the benefits and $$$$ of being an NFL player.
Sports-related concussions, also known as mild- traumatic brain injury (m-TBI), are a hot issue presently. The problem is real, as we know that some of the affected will develop lasting symptoms after injury. Additionally, there is mounting evidence that repetitive head trauma can lead to a development of a neurodegenerative disorder known as chronic traumatic encephalopathy (CTE). Untimely deaths of high-profile NFL players such as Junior Seau and Javon Belcher loom large in our memories, representing the worse-case scenario. The upcoming release of “Concussion”, featuring Will Smith as the forensic pathologist who first identified CTE in NFL players, promises to plant the risks of concussions firmly in mainstream discourse.
In real life, however, the issue is more nebulous than it will likely appear on the big screen because we can’t yet identify who will develop persistent symptoms, predict how severe the lasting effects will be, or provide effective evidence-based treatments. Furthermore, the prevalence of CTE in NFL players is unknown, as there is no “proof” or gold standard diagnosis that can be made before death.
Advanced neuro imaging, such as diffusion tensor imaging, can see injuries in the brain related to m-TBI, and along with certain blood tests holds promise to fill some of this void. The technology is impressive and can detect micro-injuries previously invisible on conventional brain MRIs. It’s exciting from a scientific standpoint, this is my area of research. But here’s the problem. While sexy, neuroimaging is not a crystal ball. We cannot yet be certain if what we are seeing is clinically significant, and our limited scientific understanding carries important implications.
The modern football player faces a dilemma, which Borland has articulated thoughtfully – if I play will I pay? The dilemma is shrouded in both fear and uncertainty. Until the present, m-TBI was underdiagnosed and underappreciated. With increasing awareness and the development of sophisticated diagnostics we will begin to solve underdiagnosis. The corollary, however, is that we will almost certainly overdiagnose. Overdiagnosis is not benign, and should grab the attention of athletes, sports-fans, and anyone in the medical community who believes their first duty is indeed to do no harm.
Football is a livelihood and a passion for many. Though Borland may be before his time, we will likely see more professional athletes confronting this decision in coming years. Undoubtedly, more will choose to walk away from the sport because of the anticipated risk of CTE. If allowed to be unjustifiably extrapolated to collegiate and high-school athletics, “concussion hype” threatens to significantly undermine participation in youth sports, the risks of which are rarely weighed against those of spending a childhood sitting on the couch. Not to mention brain injury lawyers are fixing to have a field day.
While it is clear that researchers need to address and better understand the health effects of concussions, we have an equivalent responsibility to constrain the associated hysteria. The line between promoting awareness and stoking fear is indistinct and easy to cross. Contrary to the impression often given by media, the fact is that the vast majority of individuals who experience a concussion recover fully within a short period of time, with no lasting effects. The social, developmental, and health benefits of participation in athletics also deserve to be included in the conversation.
Unfortunately, there is no simple solution to this problem at current. If we understate m-TBI, some athletes will develop consequences. If we overstate m-TBI, some professional football careers will be unnecessarily ruined, and many may forego participation in athletics altogether. The first step is to acknowledge the pitfalls of both approaches.
About the author:
Jeffrey Ware MD, is a radiology resident at the University of Pennsylvania. He researches substrates on neuroimaging for mild traumatic brain injury.
Categories: Uncategorized
Great article. While we know that mild traumatic brain injuries in football are a hot topic today, I feel as though we cannot live in a bubble. There is a always a risk we could get into an auto accident when we drive, yet we do everyday. I am not against Chris Borland’s retirement announcement. I know he has made his money and can retire this early and I am probably just jealous that he has more money at age 24 than I will ever see.
Where did I say I’d ban it?
Peter, have you ever played soccer? Genuine question. I have never played football. I hardly watch it. I’d lose no tears if NFL was scrapped, unlike the author.
Even if you could logistically ban heading the ball you’d have a hard time convincing Europeans and South Americans, who are not as risk averse as the regulated North Americans, to accept the ban.
The point with running, which you seem to have picked up, is that risk is a spectrum. There is indeed a risk with long distance running which advanced imaging techniques of the heart are increasingly showing. There are indisputable benefits of running. Running has a net benefit. You could increase the net population benefit even more by banning all races exceeding 13.1 miles.
Every sport has a risk-benefit calculus. The case against football is not an argument of kind, but an argument of degree. It is possible that the NFL hurts your sensibilities more than a classy game like tennis. But injuries from competitive sports are no less debilitating just because they do not involve the brain, just because they are incurred during a heroic dive rather than a barbaric charge. When such injuries involve the heart, as in marathoners and ultramarathoners, they can assume immediate permanence.
If your objection to NFL is driven purely by risk, not moral sensibilities, I’d expect you to rally for the banning of ultramarathons. If the sport offends you, say so, and we can dispense of the pretense of science. FWIW, I find it an unaesthetic display of structured incoordination, the very worst blend of prehistoric gladiatorship and modern day hedonism.
But I wouldn’t ban it.
“How will you enforce the ban?”
How do they enforce ban on the use of hands in soccer?
As to your claim about “long distance running” you may want to read this: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538475/
If this indeed is a problem then modification of the exercise solves the problem. However, when a sport, which is designed and incorporates risky behaviors within the rules and manner of just doing the sport, then, as in smoking, the act itself is a health risk, you either change the rules or at least for adults make them aware of the risks. For children, who have little say or understanding in being involved in risky behavior, then it’s up to grown ups to protect them. I would not allow my son to participate in tackle football – after he’s 18 I obviously have little control.
Peter would you ban “heading the ball” in soccer? How will you enforce the ban?
Your ignorance about the risks of long distance running is astounding. Do you know it causes fibrosis in the heart? Have you followed the deaths in marathon runners? Should we ban long distance running?
I know CTE is the fad of the day – but you really need to think a little bit more broadly about risk. Or read up a little before you swagger your moral indignation
Head butting can be easily banned, especially in youth soccer.
The simple act of running does not cause cardiac death, in fact it improves overall health. An underlying cardiac anomaly is not the fault of running.
Stupid comparison.
I think there will be enough black poor kids, who’s educational and employment opportunities will be restricted enough, to provide the NFL the personnel it requires to fulfill American males need for gladiator entertainment.
Peter – I am not a parent and don’t claim to know what it is like to be one, nor do not intend my answer to be construed as advice. But what I will offer is that I do not believe available evidence warrants a unilateral recommendation to bar children from participating in youth football. To state simply: if my child sustained concussion, I would follow current evidence-based recommendations of sports neurologists. Persistent symptoms warrant further consideration, caution, and restriction. If he wants to pursue a career in the NFL (with my genes little chance), that’s up to him. I would just make sure he has a reasonable grasp on the facts.
Excellent question, Peter. I believe Dr. Ware’s son will be fortunate enough not to rely on sports as a way out of poverty, so he can scare him about the potential for CTE.
Incidentally, Peter do you think we should ban soccer? You know they head the ball, & that could cause injury.
Also, I just want you all to be aware how dangerous running can be. In some, it causes sudden cardiac death. Peter, what shall we do about runners? Ban running? Echocardiograms every year?
How would you protect your son if he decided to play tackle football?
Peter – We are talking about a wide spectrum of exposure. The point is not that concussions do not carry risks, indeed they do and which I believe are underappreciated as I have written. The point is about the current level of uncertainty in what the magnitude of the risks really are, and the resultant implications. Regardless, confidently eliminating these risks will come at a price, which could also be substantial, not to mention depend on what a specific individual values. This tradeoff in my view is not being faithfully represented by the media, which seem to imply anyone who steps on a football field is destined to suffer from a neurodegenerative disorder. If you believe that contact sports at all levels should be eliminated from our society to ensure no athlete develops CTE, you must at least fairly consider the potential consequences of doing so.
“What is your evidence that this contention is not true?”
Always impossible to prove a negative.
“If you don’t believe me that the most common outcome after a single concussion is short-term resolution of symptoms and return to baseline function,”
We’re not talking “single concussion”, are we. These contact sports don’t limit to just one – that’s the whole point. A series of small concussions stacked on each othe over time.
Peter, thanks for reading. Of course there are other activities, but the associated risks must also be considered if a fair comparison is to be made. Even if we all aspire to live in a bubble, the risk is not 0. Also, as I pointed out below, concussions occur regularly in many different sports. One wonders how many of which you would favor eliminating.
If you don’t believe me that the most common outcome after a single concussion is short-term resolution of symptoms and return to baseline function, I suggest you review the concussion literature for yourself, there are scores of studies on this. What is your evidence that this contention is not true?
“If allowed to be unjustifiably extrapolated to collegiate and high-school athletics, “concussion hype” threatens to significantly undermine participation in youth sports, the risks of which are rarely weighed against those of spending a childhood sitting on the couch.”
So concussion prone sports are the only choices to spending a life on the couch?
I for one won’t miss football and the over hyped, over compensated, over subsidized, under taxed tribalism it fosters.
“Contrary to the impression often given by media, the fact is that the vast majority of individuals who experience a concussion recover fully within a short period of time, with no lasting effects.”
And from long term tracking studies you know this because?
Those who have choices will find it easier to leave football. Getting a true education with that football scholarship will go a long way to getting out before it’s too late. At UNC athletes were steered to fake courses to meet grade expectations and keep them in football and basketball. Which I’ve noticed seems to be mostly black players. For a lot of black athletes it also seems to be their only road to big paychecks.
I appreciate your comments Leonard, and I know you recognize the problem of overdiagnosis from past discussions. My hope is that the piece illustrates the struggle between these two concepts with regard to this specific issue. Indeed, as I point out, we have been erring on the side of underappreciation and underdiagnosis, which is a problem we are hopefully not too far from solving. But, I also hope to convince you that there is significant harm in suggesting that everyone who sustains a concussion is destined for brain degeneration, an impression one might get from media covering this topic.
The issue over the statement relates to the 87 of 91 NFL players that actually had signs of brain disease, but were (I’m guessing) largely asymptomatic and had returned to “normal”. Maybe they weren’t quite as content as they used to be, maybe word recall was a fraction slower, maybe they weren’t able to recognize certain faces, maybe they drank more. There’s a million effects that would be largely asymptomatic. I appreciate your work, and I’m sensitive to the over-diagnosis issue, but lack of diagnosis, or lack of awareness of subtle, yet potentially irreversible injury is also a big concern.
Thanks for your comment Dan.
If what you say is true and we will see the end of football, where do you see it stopping or will we see the end of more than just football? Concussions are distributed among many different sports.
http://www.headcasecompany.com/concussion_info/stats_on_concussions_sports
I agree with the conclusion that was expressed during the original airing of League of Denial (on Frontline). What we’re seeing is the beginning of the end of the NFL. Chris Borland is but one example – others will follow. More importantly – the insight from that show (and the upcoming movie Concussion – with Will Smith: http://www.imdb.com/title/tt3322364/ ) created a watershed moment for all parents. Before we didn’t know. Now we do. It will simply be harder and harder to recruit very young kids into a sport with these kinds of known risks. Early participation in the sport is the very funnel into the NFL. Choke the entry into the funnel – you choke the source for the kind of talent needed for NFL-level play. The season literally just started last week and already there have been 12 concussions. Four of those occurred before halftime. http://onforb.es/1UNsvzO
Leonard, thank you for your interest and comments.
Regarding your point about sub-concussive head trauma, I agree. It may be that our current definitions are concussion/m-TBI are really just not that useful.
I am a bit baffled by your concern over my statement. We know that the most common outcome for an individual after a concussion is to return to baseline function and to experience resolution of symptoms. The idea that an asymptomatic patient whom by all currently available objective and subjective measures has returned to normal is really not normal simply by virtue of not being ominscient, really is at the heart of the issue of over-diagnosis. While it may be true that if 10,000 different advanced tests on them you may indeed find something out of the 2 SD range, what is the value and harm of doing so? In fact, there is some evidence that labelling individuals as having “brain damage” after concussions is itself harmful, negatively impacting expectations and outcomes.
I agree completely with you on the idea that individuals have vastly different risk/benefit priorities with regards to this issue. In fact, this was my primary motivation for writing this article and presenting different sides of the issue, to provide some framework for understanding why it is reasonable for people in similar positions to choose vastly different courses.
I have chosen to dedicate much time and effort in researching this topic because I believe so strongly in its importance and that it negatively impacts many individuals. I also stand firm in believing that we have a responsibility to constrain the hype and counter unjustified extrapolation.
The old underdiagnosis-overdiagnosis dilemma.The problem is real, so is the potential for overdiagnosis. How many athlete’s do we overcall to save one athlete from CTE? 10? 100? 1000? 10, 000?
Here’s the link: http://www.pbs.org/wgbh/pages/frontline/sports/concussion-watch/new-87-deceased-nfl-players-test-positive-for-brain-disease/
And then there’s this… 87 of 91 deceased NFL players show signs of brain disease. What concerns me about head injuries, particularly as a former neuroscience grad student, is statements like, “the vast majority of individuals who experience a concussion recover fully within a short period of time, with no lasting effects.”
In fact, we don’t know about the lasting effects, because we don’t actually have the tools to measure ALL the effects. Brains are complicated, and we only measure a short list of things in a very imprecise manner.
For the record, I’m a (now reluctant) fan of football and the NFL, and have been since growing up in Ohio, but we need to find better ways to make it safe. We can’t sacrifice minds and lives for the sake of a game, no matter how entertaining.
A corollary to all this is that players like Chris Borland, who went to private high school and grew up middle class (or better), Chris has a very different risk/reward calculation than a player who grew up disadvantaged, where the NFL might be their best hope for a better life.
TBI is a problem, but so are sub-concussive hits. http://www.ncbi.nlm.nih.gov/pubmed/20883154 lineman who don’t get concussions, but repeated hits, may be at greater risk.
I’m hopeful that apps that can set a baseline, and test for impairment can be a low-cost part of the solution, so people can get an idea of where they’re at without an MRI. One group in Boulder is doing great work in this regard: http://www.bellesfarm.com/