High School Football: Time out. - PowerPoint Presentation

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High School Football: Time out.

Steven Miles MDDepartment of MedicineCenter for BioethicsUniversity of Minnesota

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Objectives: Participants will

Understand the relevance of the organization of pre-college football to reforms to reduce brain trauma.

Be able to apply current science on the effects of pre

-college football

as it relates brain

trauma

.

B

e able to design a better informed consent for school football.

Be able to evaluate proposals for game modification as

it relates brain trauma

.

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Demographics

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4.1 Million Students Play League Football

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The Science of Repetitive Brain Trauma

NOTE: For clarity,

I am focusing on studies of high school students and will

not

include

studies of NFL or

college players. I also do not discuss acute catastrophic brain injuries (e.g. hemorrhages)

or

neck

, spine, orthopedic or visceral injuries

.

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Definition: Collision Sport

Athletes purposely and frequently hit or collide with each other or inanimate objects with great force. American football, rugby, boxing, ice hockey, full contact martial arts.

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J

Athl Train. 2007;42: 495–503.

Note: Concussions are undercounted.

Subconcussive

Repetitive Brain Trauma not counted.

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ConcussionA subset of Traumatic Brain Injury. Low velocity injury that causes brain ‘shaking’ resulting in clinical symptoms. May be caused by a direct blow to the head or by an "impulsive" force transmitted to the head.Typically, rapid-onset, short-lived impairment resolving spontaneously or evolving over minutes to hours to longer. May involve loss of consciousness. May cause neuropathology but is largely a functional disturbance rather than structural injury.

Traumatic Brain Injury

A blow or jolt to the head, or a penetrating head injury that disrupts normal brain function.

Can result from the head violently hitting an object, or an object pierces the skull to enter brain tissue.

Symptoms can be mild to severe.

Mild traumatic brain injury may result in a brief change in mental state or consciousness, while severe cases may result in extended periods of unconsciousness, coma or death.

4th International Conference on Concussion in Sport held in Zurich, Switzerland in 2012

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Chronic Traumatic Encephalopathy

Always follows repeated brain trauma.A neurodegenerative disease.Wide deposition of hyperphosphorylated tau (P-tau).Some correlation with APO ε3. Neurology 2013;81;1122-1129

Young onsetInitial behavioral/ mood disturbance Minimal motor cognitive disturbance

Older onsetCognitive and motor impairments

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Players received 200 to 1,850 hits to the head / season. Impact forces: 20 to 100+ Gs! Max was 280Gs. [Headkick in soccer is ~20 Gs.] 3x as many players showed brain changes as experienced concussion.

Base

Preseas

Seas 1

Post

J

Biomech

2012;30;45:1265-72. Two year study of high school football players. Helmet Accelerometers. fMRI. Develop Neuropsych 2015;40(2):92-7.

"The level of change in the fMRI signal is significantly correlated to the number and distribution of hits that a player takes. Cognitive performance didn't change, but brain activity changes, showing that certain areas are no longer being recruited to perform a task.

”

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Age of first exposure to tackle football and later-life corpus callosum (CC) microstructure using MRI diffusion tensor imaging

40 retired NFL

players,

age

40-

65,

matched by age

were divided

into two groups

(before

/ after age

12) of first exposure (AFE) to

tackle

football.

F

ormer

NFL players in the AFE <12 group had significantly lower

Fractional Anisotropy and higher radial diffusivity (indicating impaired white matter connectivity) in the corpus callosum than

those in

AFE

≥12 group

.

J Neurotrauma 2015;32:

1768-76

.

Develop

Neuropsych

2015;40:

92-

7.

J

Neurotrauma

2014;31:

1617-

24.

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Repetitive Head Impact (RHI) and Long Term Cognition

RHI is the idea that cumulative exposure to concussive and subconcussive events damages the brain. The Cumulative Head Impact Index CHII quantifies RHI by combining self-reported athletic history (i.e., # of seasons, position(s), etc,) and impact data from helmet accelerometers. A threshold dose-response relationship was found between CHII andlater-life cognitive impairment (p<0.0019), self-reported executive dysfunction (p<0.0003), depression (p<0.0009), apathy (p<0.0040), behavioral dysregulation (p<.0001)

J

Neurotrauma

. March 2016. doi:10.1089/neu.2016.4413. 93 former high school and collegiate football players that completed objective cognitive & self-reported behavioral/mood tests as part of a larger longitudinal study.

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Athletes with recent concussions performed had worse attention and concentration.Symptom-free athletes with two or more concussions performed like youth with a recent concussion. Cumulative GPAs were lower for athletes with two or more previous concussion groups and for those with recent concussions.Neurosurg 2015;57:300-6. 223 boarding high school athletes.J Neurotrauma 2014;31:327-38.

Number of Concussions

Number of Concussions

.006

.012

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CTE in young people

"I unequivocally think there's a link between playing football and CTE, . . . [in five years] we've found it in 45 out of 55 college players and 6 out of 26 high school players.” “It cannot be rare.”Its not about limiting concussions; its about limiting head injuries.Dr. Ann McKee, professor of neurology and pathology at Boston University. Testimony. House Energy Committee Hearing 3/14/16. https://energycommerce.house.gov/hearings-and-votes/event/broad-review-concussions-initial-roundtable

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Joseph Chernach played football grades 5-12 and stopped. 2009-2012: His mood and academic performance steadily deteriorated in college.2012: Suicide by hanging at age 25. 2016 Pop Warner paid “less than $2 million” to family.

“Very

severe changes in the brainstem, with

numerous

tau

neuro-fibrillary

tangles in the locus

coeruleus

. . .

These

findings indicate Stage II, possibly Stage III

CTE.

”

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Game Modification?

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Preventing Repetitive Head Injury in Youth Football

There is no evidence-based validation of:

Reformed Return to Play Policies (Either design or enforcement).

Improved helmet design

Changes in tackling rules (except for some rules on kick-off returns)

The Heads-Up program of USA Football or CDC.

Kids reporting symptoms of concussion

J Law

Med. & Ethics

2014;42:323-9

N

Engl

J Med 2016; 374:405

-7.

Amer J

Sports

Med 2014;42:

2470-

8.

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The American Academy of Pediatrics 2015 Statement.

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The AAP’s child-centered mission is “to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults.” 1957: “football has no place” for children under 121968: Competitive Athletics for Children of Elementary School Age. “Unless a school or community can provide exemplary supervision medical and educational it should not undertake a program of competitive sports, especially collision sports, at the pre-adolescent level.”

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2015: Young athletes pose a unique challenge, because their brains are still developing and may be more susceptible to the effects of a concussion. “Removing tackling from football altogether would likely lead to a decrease in the incidence of overall injuries, severe injuries, catastrophic injuries, and concussions. . . . [however, removing] tackling from football would lead to a fundamental change in the way the game is played. Participants in football must decide whether the potential health risks of sustaining these injuries are outweighed by the recreational benefits associated with proper tackling.”

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L

ead author has a non-disclosed conflict of

interest. Dr.

Mark E. Halstead

is a team physician for the St. Louis Rams, St. Louis Blues, Washington University Athletic Teams, and Lafayette High School.

Entirely focused on concussion. No discussion of repetitive

subconcussive

trauma.

P

assing reference to the

effects of concussion on academic

performance.

No evidence

-based template for informed

consent.

Optimistically

speculative

(e.g. proposing neck

strengthening might decrease the catastrophic neck injuries or cautions that that raising the age at which tackling is allowed might increase injuries

.)

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Informed Consent

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Standard Consent

Doesn’t disclose risks. Misleading contextualization (e.g., “There is a degree of risk in all daily activities.”) Doesn’t rebut ungrounded hope of 26% of parents, especially those with economic and educational disadvantages, that their child will turn school participation into a professional athletic career. Mainly liability waivers.Amer J Bioeth 2016;16:6-10.

Parents and students should be aware of prelim-inary evidence that suggests repeat concussions, and even hits that do not cause a symptomatic concussion, may lead to abnormal brain changes which can only be seen on autopsy (known as Chronic Traumatic Encephalopathy (CTE)). There have been case reports suggesting the development of Parkinson’s-like symptoms, Amyotrophic Lateral Sclerosis (ALS), severe traumatic brain injury, depression and long term memory issues that may be related to concussion history. Further research on this topic is needed before any conclusions can be drawn.

Florida High School Athletic Association- 2016

http://

www.fhsaa.org

/sites/default/files/

orig_uploads

/

gov

/

sportsmed

/minutes/160308.

pdf

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Honest Informed Consent

Repetitive brain injuries are common in youth football although the long term effects on a particular player cannot be predicted.A symptomatic concussion increases the risk of future concussions, future brain injuries and the chance of a catastrophic injury resulting in paralysis or death. Repetitive head trauma from tackle football is likely to adversely affect attention, memory, and school performance for weeks and possibly for the long term.Coaches cannot detect most brain injuries. Brain damaging injuries do not require the symptoms of a concussion. Some young people get progressing and untreatable brain diseases from participating in collision sports like football. This can result in poor college, occupational and social performance and depression.

School football is not a likely path to a college scholarship or a professional sports career. 1 /16 high school football players will play on a college team. 1 / 1,200 high school football players will play on a pro team. The average pro career is 3.3 years. Pro players have much higher rates of depression, thinking problems, and physical disabilities than the general public.

General medical insurance is the student’s responsibility. The school does not provide or pay for long-term rehabilitation or vocational retraining, long term care or adaptive aids like crutches or wheelchairs. The school does not provide disability insurance for lost income.

Amer

J

Bioeth

2016;16:6-10.

Amer

J Sports Med 2015;43:1260-4.

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Social Trends

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Social Trends

Prior to 2015.School football declining .5% per year. http://www.nfhs.org/ParticipationStatics/ParticipationStatics.aspx/Non-school football declining 4% per year. http://espn.go.com/espn/otl/story/_/page/popwarner/pop-warner-youth-footballparticipation-drops-nfl-concussion-crisis-seen-causal-factorThe 2014-2015 trend (different method): tackle football up 2-2.5 % in 2015 as flag football up 9-10%. http://usafootball.com/blog/americas-game/participation-tackle-and-flag-football-increases-2015

School tackle practices are decreased. (Ivy League has given up tackle practices.)

Some schools and cities are ending tackle programs.

Age for tackle being raised.

“Stronger” rules for taking players out.

“Stronger” head trauma training for coaches.

More medical expertise at game side (often not practices).

There are increasing numbers of lawsuits against teams, leagues, schools, and state football associations.

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An Immodest Proposal

NB: Mr. Swift proposed to consume children for the ‘public good.’ I propose that we stop doing so.

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Close Down School Football Programs

It would decrease incentives to play for the school or to reap academic rewards (excused time, leniency in academic performance).It would refocus school physical education programming and resources to fitness sports of life-time participation (e.g., working out, jogging, tennis, bicycling, swimming) rather than spectator or team sports. http://www.physicalactivitycouncil.com/pdfs/current.pdfIt would not end the ‘right’ to play football although it would reduce public expenditures for football.

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Game Over

Steven Miles MDmiles001@umn.eduSlides available at my faculty website