28 November 2012. When a Pittsburgh medical examiner reported chronic traumatic encephalopathy in former Steelers players who had died young (Omalu et al., 2005; Omalu et al., 2006), the specter of neurodegeneration in concussed athletes quickly gained momentum. Close to the New England Patriots' hometown, Christopher Nowinski, a former Harvard football player and cage wrestler, joined forces with concussion expert Robert Cantu to found the advocacy organization Sports Legacy Institute in 2007. In 2008 they partnered with neuropathologist Ann McKee and clinical neurologist Robert Stern to form the Center for the Study of Traumatic Encephalopathy at Boston University School of Medicine. Together, the group published a review of known cases to date, putting CTE on the map as a progressive tauopathy and starting a national media drive on the topic (McKee et al., 2009). Last month in Las Vegas, Nevada, these scientists, Nowinski, and many others gathered for a conference on CTE at the Cleveland Clinic Lou Ruvo Center for Brain Health to articulate a research agenda for CTE (see Part 1, Part 2, Part 3, Part 4, and Part 5 of this series). The advocacy of the past five years has forced some changes. It has recently opened a second front by fighting concussions in contact sports in children.

The film Head Games documents the dangers of head trauma, particularly to children who play contact sports. (Click on image to view film trailer.)

The NFL stonewalled for a while, Cantu told the audience. Famously, Ira Casson, formerly of the league’s TBI committee, earned the moniker “Dr. No” for his one-word answers in an HBO interview to questions about links between multiple head injuries and neurologic consequences including dementia. Casson also avoided clear statements in a 2008 Alzforum Live Discussion on the topic with leading CTE researchers (see transcript).

Recently, however, the NFL made changes to reduce head trauma. It moved the kickoff line, banned concussion-prone maneuvers such as the three- or four-man wedge, and forbade hitting an unseeing opponent above the neck. When players lose consciousness or are symptomatic, they have to stay out of the game or the practice that day. Amateur leagues followed these NFL reforms within months, Cantu said. Moreover, NFL teams must now have an independent neurologist who decides when it is safe for the athlete to return to play. The league imposed penalties up to suspension for hitting the head of a "defenseless" player, that is, someone looking at the ball. A referee can now send a player suspected of having a concussion to the sideline to be checked by the medical team, as is done in martial arts. Implementation continues to be marked by conflict, however (e.g., see ESPN story).

Importantly, said Nowinski, NFL games now ensconce an athletic trainer high up in a skybox overlooking the field who views instant TV replays and can call players suspected of a concussion to come to the sideline for a medical check. “These guys up high see more concussions than sideline refs,” said Nowinski. The changes are not enough, Cantu said. “If the NFL wants to go to the next level in player protection, it needs to make all intentional hits to the head illegal.”

The NFL is directing funding to the problem. In September, timed to the start of the regular season, the league announced a $30 million donation to the Foundation of the National Institutes of Health in its single largest grant to any organization in the past, according to the league. Part of the NFL’s agreement with the players' union, this gift is meant for research on brain injuries that will benefit soldiers as well as athletes and the general population. NFL Charities, the foundation of NFL owners, is providing $1.5 million for 15 research grants, such as a recent one to the Concussion Management Clinic at the University of Buffalo School of Medicine, to develop scientific methods to determine when an athlete can safely return to play.

On Thursday 15 November, NFL commissioner Roger Goodell addressed the Harvard School of Public Health after three quarterbacks had sustained concussions in the previous Sunday’s games, and on 19 November, Goodell announced that the league would convert players’ medical records to an electronic health record system (see Goodell video/story).

For their part, Nowinski and Cantu have shifted their attention to protecting children. “We know that diagnosis and treatment development will take years,” Nowinski said. “Meanwhile, we can prevent future cases now.”

At the Las Vegas conference, Nowinski reminded researchers that children are at higher risk of CTE than adults because the axons in their central nervous systems have less protective myelination. Myelination continues throughout a person’s youth. Their heads are relatively larger than those of adults compared to their body size, and their neck muscles are weaker. “Essentially, they are like bobble head dolls when it comes to being whacked on the head. They are at a biomechanical disadvantage,” Nowinski said. Helmet sensors such as built-in accelerometers and gyroscopes are telling scientists that the force of a hit to the head for a high school football player is about the same as the main force to the head for college players, about 18 to 22 gravity force (G force). “For young kids it is 15 G force. That is much too high for a large head on a weak neck,” said Nowinski.

Blaine Hoshizaki, of the School of Human Kinetics at Ottawa University, studies the head’s dynamic response to different types of hits—falls, collisions, punches, and impact from flying objects such as pucks and baseballs. Hoshizaki’s team reconstructs real head injuries captured on video, for example, of this NHL hit that kept the concussed player off the ice for a year. The Ottawa scientists measure the dynamic response of the head, including both linear and angular head acceleration in the x-, y-, and z-axes, and use those data to calculate brain tissue deformation that follows from it. Present-day helmet standards only employ linear acceleration to measure helmet protection, while it is angular acceleration that is more closely associated with concussive injuries. It is important to develop a testing protocol for evaluating helmets that include both linear and angular acceleration, Hoshizaki told the Las Vegas conference audience. He also said that the type of impact to the head determines the resulting trauma to the brain. Depending on whether the athlete was part of a collision, fell to the ground, was punched, or hit by an object determines the location and type of brain tissue damage.

The Sports Legacy Institute is now pushing a hit count initiative. The idea follows the more established pitch counts that protect the elbows of young baseball players, with national limits to how many pitches a youngster can throw and mandated rest (see White Paper). “We have nothing similar for hits to the head yet. Hit count data in the literature are as high as several thousand in high school, more than half of it in practice,” said Nowinski.

While middle and high schools have started baseline concussion testing for most field sports at the beginning of each academic year, youth football in particular continues to proceed without medical training requirements or revised practice procedures for coaches. The issue is gaining attention in the media, rattling parents and Pop Warner itself. On 23 October, The New York Times ran a story on a pee-wee game in central Massachusetts that carried on to a final score of 52-0 even as five 10-year-olds received head injuries. That evening, National Public Radio quoted Cantu as saying that boys younger than 14 should not play collision sports, a position he also took at the Las Vegas conference. Cantu recently published a book on the subject (Concussions and Our Kids). This fall, director Steve James, of Hoop Dreams fame, released his new documentary film Head Games, based on Nowinski’s book of the same title.

“Is this the beginning of the end of football? No. But maybe for young kids it is,” Nowinski said.—Gabrielle Strobel.

This concludes a six-part series. See Part 1, Part 2, Part 3, Part 4, Part 5. Read a PDF of the entire series.