Kids and Football

by Guy McKhann, M.D.

December 30, 2015

This is a column from Dana's print publication, Brain in the News 

Don’t Let Kids Play Football” is the title of a New York Times OpEd column by Bennet Omalu. Dr. Omalu gets credit for being the first to recognize the distinctive neuropathology associated with repeated head injuries in an NFL player. Omalu was on call when an autopsy was needed for former Pittsburgh Steeler Mike Webster. Not being a football fan, Omalu was one of the few adult males in Pittsburgh unfamiliar with Webster, a star center for 17 seasons. Some time after Webster’s retirement in 1990, he gradually began to deteriorate mentally, first with depression and paranoia, then gradual loss of cognition, so that at the time of his death, he was essentially demented. Because of his football notoriety, his troubles were documented in the local newspapers. Omalu’s unawareness made the autopsy a truly double-blinded undertaking.

Omalu realized that he was seeing a very unique pathology. The gross brain appeared normal, but when he cut into it and made stained sections, he noted the marked accumulation of the protein tau. Tau, in the form of tangles, is one of the hallmarks of Alzheimer’s disease, as is the accumulation of another protein, beta amyloid, in the form of plaques. In Webster’s brain there were very few amyloid-containing plaques and the tau accumulation was in a different distribution than what one would see with Alzheimer’s. Omalu and his colleagues published two papers in the journal Neurosurgery: one on Webster and another on fellow Steeler Terry Long. They described their findings, suggesting that repeated head injuries might be associated with this pathology. All hell broke loose. The NFL powers that be were not happy that their sport might be associated with brain damage. Several physicians involved with NFL teams wrote the journal asking that the papers be withdrawn. (Withdrawing a paper rarely happens, and is done when there is clear misconduct such as fraud). The papers were not withdrawn.

Deciding that challenging the powerful NFL was an impossible task, Omalu left Pittsburgh and became a medical examiner in California, out of the limelight. However, Dr. Ann McKee, a well-regarded neuropathologist in Boston, picked up the slack and let the world know she and her colleagues were available to do the neuropathology on athletes, and military personnel, with head injuries. She was joined by a neurosurgeon, Robert Cantu, and Chris Nowinski, a former Harvard football player and professional wrestler, who became concerned about his own history of head injuries. Chris has become the liaison between the Boston investigators and the athletic world, active in obtaining permission and access for the Boston group to do autopsies. As of September 2015, they’ve analyzed the brains of 91 former NFL players and found the distinctive pathology in 87 (96 percent).

The clinical course in the others is much like that of Mike Webster: exposure to a series of head injuries over years, a period of normal functioning after retirement, and gradual decline in cognitive functions. What’s going on in these brains? We really don’t know. However, one possibility is that the accumulation of tau is initiated by head trauma. Even after the trauma stops, the accumulation continues until tau reaches a level that is toxic to nerve cells. This process may take years and might be exacerbated by the person’s use of alcohol or drugs.

We soon may learn more, thanks to the recent development of the ability to use brain imaging to detect tau in the living brain. This is done by administering a ligand, a substance that binds to tau, and detecting it with a brain scan. It’s a new technology, and there are several different ligands being evaluated. Assuming this technology can be honed in the next few years, it would be possible to scan a group of college (or younger) players as they start their careers and rescan them five to six years later to check for tau accumulation. The players could be seen annually to determine their head injury histories, or could even wear a helmet designed to detect the force of blows to the head.

So should kids play football? I have nine grandchildren. My youngest, twin seven-year-old boys, are into gymnastics and swimming, so they’re not at risk of head injuries (though they enjoy pummeling each other). The others are into soccer, lacrosse, mountain climbing, and cross country skiing. What would I tell them? I think that there is a lot of hand-waving about the susceptibility of the developing brain. In some instances the younger brain is more resistant to injury. An eight-year-old can survive and make a remarkable recovery from a stroke, while a similar stroke in an 80-year-old would be devastating. However a diffuse injury (one that is spread more widely), associated with a head injury, may have effects on brain development.

I don’t know where to draw the line regarding age. I suggest that prior to age 18 kids play less violent forms of football, like touch or flag football, to significantly reduce the chance of head injury.

For a fuller description of the evolution of information about head injuries in football players, visit the website for the Frontline documentary League of Denial: The NFL’s Concussion Crisis. There is also an upcoming major motion picture, Concussion, in which Will Smith portrays Dr. Omalu in his battle with the NFL.