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.