Is the NFL neglecting its players? A brief history of chronic traumatic encephalopathy

A word on nomenclature. “Punch-drunk” boxing had been described by Martland in 1928 among prize fighters, but the formal term chronic traumatic encephalopathy would not be coined until 1940 by Bowman and Blau when the authors described the case of a 28-year-old boxer whose wife reported that for the two previous years the patient had exhibited increasingly childish behavior, depression, paranoia and many other symptoms. And now, we are more frequently recognizing these symptoms in NFL players. This week on BrainWaves, we talk about the history of concussion and the NFL’s response to failed safety measures in preventing disabling neurologic injury among their players.

One question I’d like to start off with is, why are we recognizing these complications all of the sudden? American football dates back to the end of the Civil War (coincidentally about the same time when American neurology was born). The first American football game took place between Rutgers and Princeton in 1869, and the NFL was founded in 1920. But there was no uprising about chronic neurologic symptoms of ex-football players during this time. However, if you look closely, there were case reports and speculations dating back to the 1890s where players were advised to avoid repeated head injuries in order to prevent “traumatic insanity,” but this was far from widely accepted. Some speculate1945 Helmet that the low incidence of CTE before the 1990s and early 2000s may be due to the low number of players who began to participate in football at a young age—football really was an adult sport for many decades. More likely, it had something to do with the relatively infrequent number of head-to-head contact injuries before the invention of the present day football helmet, which makes many players feel nearly invincible. The first helmet, made entirely of leather (see image), was put to use in 1893 in an Army-Navy game, however the use of helmets would not be required by any professional American football organization until the 1930s, when college football mandated their use in 1939 and the NFL in 1943. Plastic was added to the helmet about this time, but these remained brittle so high-impulse head contact probably didn’t pick up just yet. Finally in 1971, “microfit” helmets made of plastic with inner cushions that could be inflated like miniature airbags in order to sustain high impulse blows. Since then, we really haven’t made too many modifications, and I bet this has a lot to do with why we only started noticing symptoms of CTE in the 1990s—a nice 20 years after the implementation of these “protective” devices, which really only encourage more serious head-to-head collisions.

In addition to the history of concussions in the NFL, and some of the players affected–even more recently Cam Newton of the Carolina Panthers–we also talk about the risk of concussion and CTE among players, the “second impact syndrome,” the relationship between age of first football exposure and CTE, and other disturbing findings from recent clinical research.

So where do we go from here? There are a number of major research initiatives whose primary aims are to better understand the development of CTE and how athletes can minimize risk. To name a few, the UNITE trialists, the NCAA-DOD Grand Alliance Concussion Assessment, Research and Education Consortium and the BIG 10/Committee on Institutional Cooperation-Ivy League Traumatic Brain Injury Research Collaboration are among the groups best funded to determine the epidemiology and clinicopathologic consequences of mild, repeated TBI. The NFL has even put some money into this, after the last decade of castigation from Bennet Omalu and colleagues. Did you see the movie, Concussion? If you haven’t, you should. I know I criticize some of the historical elements of the film in my Neurology® review, but it’s not a bad intro to why brain injury has become so popular in the recent media.

All this being said, am I really going to stop watching the Saints on Sundays? Probably not. But that’s not to say I won’t do my part in raising awareness on this major health issue whose ramifications extend WAY beyond the NFL. And I hope that parents, coaches and multi-billion dollar enterprises like the NFL will continue to appropriately educate their children, players, and employees about the risks and benefits of this great American pastime.

 

[Jim Siegler]


REFERENCES

Montenigro PH, Corp DT, Stein TD, Cantu RC and Stern RA. Chronic traumatic encephalopathy: historical origins and current perspective. Annu Rev Clin Psychol. 2015;11:309-30.

Giza CC, Kutcher JS, Ashwal S, Barth J, Getchius TS, Gioia GA, Gronseth GS, Guskiewicz K, Mandel S, Manley G, McKeag DB, Thurman DJ and Zafonte R. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80:2250-7.

Guskiewicz KM, Marshall SW, Bailes J, McCrea M, Cantu RC, Randolph C and Jordan BD. Association between recurrent concussion and late-life cognitive impairment in retired professional football players. Neurosurgery. 2005;57:719-26; discussion 719-26.

Stamm JM, Bourlas AP, Baugh CM, Fritts NG, Daneshvar DH, Martin BM, McClean MD, Tripodis Y and Stern RA. Age of first exposure to football and later-life cognitive impairment in former NFL players. Neurology. 2015;84:1114-20.

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