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Opportunities for Prevention of Concussion and Repetitive Head Impact Exposure in College Football Players : A Concussion Assessment, Research, and Education (CARE) Consortium Study

• 1 Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
• 2 Department of Biomedical Engineering, Virginia Tech, Blacksburg
• 3 School of Public Health-Bloomington, Department of Epidemiology and Biostatistics, Indiana University, Bloomington
• 4 Department of Psychiatry, Indiana University School of Medicine, Indianapolis
• 5 Michigan Concussion Center, University of Michigan, Ann Arbor
• 6 UCLA Steve Tisch BrainSPORT Program, Department of Neurosurgery, University of California at Los Angeles
• 7 UCLA Steve Tisch BrainSPORT Program, Department of Pediatrics, University of California at Los Angeles
• 8 Department of Family Medicine and Orthopedic Surgery, University of California at Los Angeles
• 9 John A. Feagin Jr Sports Medicine Fellowship, Keller Army Hospital Military Academy, West Point, New York
• 10 Department of Physical Medicine and Rehabilitation, Uniformed Services University, Bethesda, Maryland
• 11 Air Force Academy, Colorado
• 12 Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, Department of Exercise and Sport Science, University of North Carolina at Chapel Hill
• 13 Department of Orthopedics and Rehabilitation, School of Medicine and Public Health, University of Wisconsin, Madison
• 14 Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee
• Editorial Who Will Protect the Brains of College Football Players? Christopher J. Nowinski, PhD; Robert C. Cantu, MD JAMA Neurology

Question   Where might there be opportunities to do the greatest good toward reducing overall concussion incidence and head impact exposure (HIE) in collegiate football?

Findings   In this cohort study, concussion incidence and HIE were disproportionately higher in the preseason than the regular season, and most concussions and HIE occurred during football practices.

Meaning   These findings point to specific areas where public policy, education, and other prevention strategies could be targeted to make the greatest overall reduction in concussion incidence and HIE in college football, which has important implications for protecting the safety and health of collegiate football players.

Importance   Concussion ranks among the most common injuries in football. Beyond the risks of concussion are growing concerns that repetitive head impact exposure (HIE) may increase risk for long-term neurologic health problems in football players.

Objective   To investigate the pattern of concussion incidence and HIE across the football season in collegiate football players.

Design, Setting, and Participants   In this observational cohort study conducted from 2015 to 2019 across 6 Division I National Collegiate Athletic Association (NCAA) football programs participating in the Concussion Assessment, Research, and Education (CARE) Consortium, a total of 658 collegiate football players were instrumented with the Head Impact Telemetry (HIT) System (46.5% of 1416 eligible football players enrolled in the CARE Advanced Research Core). Players were prioritized for instrumentation with the HIT System based on their level of participation (ie, starters prioritized over reserves).

Exposure   Participation in collegiate football games and practices from 2015 to 2019.

Main Outcomes and Measures   Incidence of diagnosed concussion and HIE from the HIT System.

Results   Across 5 seasons, 528 684 head impacts recorded from 658 players (all male, mean age [SD], 19.02 [1.25] years) instrumented with the HIT System during football practices or games met quality standards for analysis. Players sustained a median of 415 (interquartile range [IQR], 190-727) recorded head impacts (ie, impacts) per season. Sixty-eight players sustained a diagnosed concussion. In total, 48.5% of concussions (n = 33) occurred during preseason training, despite preseason representing only 20.8% of the football season (0.059 preseason vs 0.016 regular-season concussions per team per day; mean difference, 0.042; 95% CI, 0.020-0.060; P  = .001). Total HIE in the preseason occurred at twice the proportion of the regular season (324.9 vs 162.4 impacts per team per day; mean difference, 162.6; 95% CI, 110.9-214.3; P  < .001). Every season, HIE per athlete was highest in August (preseason) (median, 146.0 impacts; IQR, 63.0-247.8) and lowest in November (median, 80.0 impacts; IQR, 35.0-148.0). Over 5 seasons, 72% of concussions (n = 49) (game proportion, 0.28; 95% CI, 0.18-0.40; P  < .001) and 66.9% of HIE (262.4 practices vs 137.2 games impacts per player; mean difference, 125.3; 95% CI, 110.0-140.6; P  < .001) occurred in practice. Even within the regular season, total HIE in practices (median, 175.0 impacts per player per season; IQR, 76.0-340.5) was 84.2% higher than in games (median, 95.0 impacts per player per season; IQR, 32.0-206.0).

Conclusions and Relevance   Concussion incidence and HIE among college football players are disproportionately higher in the preseason than regular season, and most concussions and HIE occur during football practices, not games. These data point to a powerful opportunity for policy, education, and other prevention strategies to make the greatest overall reduction in concussion incidence and HIE in college football, particularly during preseason training and football practices throughout the season, without major modification to game play. Strategies to prevent concussion and HIE have important implications to protecting the safety and health of football players at all competitive levels.

• Editorial Who Will Protect the Brains of College Football Players? JAMA Neurology

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McCrea MA , Shah A , Duma S, et al. Opportunities for Prevention of Concussion and Repetitive Head Impact Exposure in College Football Players : A Concussion Assessment, Research, and Education (CARE) Consortium Study . JAMA Neurol. 2021;78(3):346–350. doi:10.1001/jamaneurol.2020.5193

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Concussion in soccer: a comprehensive review of the literature

Affiliations.

• 1 Department of Neurosurgery, University of Alabama at Birmingham, 1813 6th Ave S #516, Birmingham, AL 35233, USA.
• 2 Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224, USA.
• 3 Department of Neurosurgery, Brigham & Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA.
• PMID: 33005435
• PMCID: PMC7506470
• DOI: 10.2217/cnc-2020-0004

Sports-related concussion has been examined extensively in collision sports such as football and hockey. However, historically, lower-risk contact sports such as soccer have only more recently garnered increased attention. Here, we review articles examining the epidemiology, injury mechanisms, sex differences, as well as the neurochemical, neurostructural and neurocognitive changes associated with soccer-related concussion. From 436 titles and abstracts, 121 full texts were reviewed with a total of 64 articles identified for inclusion. Concussion rates are higher during competitions and in female athletes with purposeful heading rarely resulting in concussion. Given a lack of high-level studies examining sports-related concussion in soccer, clinicians and scientists must focus research efforts on large-scale data gathering and development of improved technologies to better detect and understand concussion.

Keywords: football; repetitive subconcussive head impact; soccer; sport injuries; sport-related concussion; traumatic brain injury.

© 2020 James Mooney.

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Lights Out: Concussion Research, the National Football League, and Employer Duty of Care

• First Online: 01 January 2022

Cite this chapter

• Lucia Trimbur 3  

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This chapter looks at the epic struggle between the National Football League (NFL) and social actors concerned about football, brain injury, and chronic traumatic encephalopathy (CTE). In particular, it analyzes the registers in which the NFL, on the one hand, and research scientists who work with players and their families, on the other, have situated their evidence and arguments. I argue that though both sides have strong investments in either proving or minimizing the football-concussion-CTE connection, what has been missing from the debate is any conception or even language of labor: how players are workers, how the football field is their worksite, and how athletes should be afforded attendant occupational health protections to reduce risk of injury.

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Because the focus of this paper is on the National Football League (NFL), which right now is exclusively male, I look at concussion, CTE, and male American football players. There are an increasing number of women taking up the sport and their rigor and commitment often matches that of their male counterparts. Future research will need to take into account their experiences.

Other brain injuries include scalp abrasions, contusions, and lacerations; skull fractures; and brain contusions and lacerations (Omalu, 2008 , p. 9).

The National Football League was not the only level of play that saw early career ends. Between the 2013 and 2015 season, at least 26 players in competitive Division 1 NCAA programs left the sport because of concussions (Bella, 2015 ).

Much is still unknown about the causes of CTE and scientists do not know why people with similar histories of brain trauma have different outcomes. There are cases of people who experienced repetitive brain injury and did not develop CTE. And the disorder has never been found in someone who only had one concussion. Why one develops CTE and another does not is still unclear (Concussion Legacy Foundation, 2019 ).

Omalu’s work has come under fire by researchers in the field and pieces such as “From Salesman to Scientist” published on January 22, 2020, in The Washington Post , question the validity of his scientific conclusions. I am in no position to evaluate his findings but I do not believe that CTE would be on the world stage if Omalu had not examined Mike Webster’s brain and researched its pathology.

Anti-black racism and xenophobia no doubt affected the reception of Omalu’s work as he was born in Nigeria and migrated to the US in 1994.

Pellman was not only skeptical of concussion, he was also skeptical of people who suffered them. He suggested, “Veterans clear more quickly than rookies. … They can unscramble their brains a little faster, maybe because they’re not afraid after being dinged. A rookie won’t know what’s happened to him and will be a little panicky. The veterans almost expect the dings. You have to watch them, though, because vets will try to fool you. They memorize the answers. They’ll run off the field staring at the scoreboard” (Coates, 2013 ).

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Trimbur, L. (2021). Lights Out: Concussion Research, the National Football League, and Employer Duty of Care. In: Wagg, S., Pollock, A.M. (eds) The Palgrave Handbook of Sport, Politics and Harm. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-72826-7_7

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Media Center 2/1/2021 5:19:00 PM

CARE Consortium finds higher incidence of concussion, head impact exposure during football preseason and practice

New research from ncaa-funded study shows restructuring preseason and practice protocols may reduce concussions.

The latest findings from the Concussion Assessment, Research and Education Consortium show that disproportionately higher concussion rates and head impact exposure in college football occur during the preseason and practice — not regular-season games.

The largest and most comprehensive clinical study of concussion and head impact exposure in history, the CARE Consortium is funded by the NCAA and U.S. Department of Defense with broad aims to enhance the health and safety of NCAA student-athletes and military service members. It also serves as a valuable resource for youth sports participants and society at large.

"As a higher education association, we believe strongly in the power of research to inform decision-making and with it drive action," NCAA President Mark Emmert said. "The NCAA and its members have supported this monumental study to help answer many of the questions around the diagnosis, treatment and prevention of concussions. These latest findings provide new information for our members to modify rules while continuing education efforts for college athletes across the country."

Researchers conducted this phase of the study using head impact sensor technology that measures head impact frequency, location and magnitude. Researchers found that across six Division I football programs from 2015 to 2019, almost half of the reported concussions and two-thirds of reported head impact exposure across all players occurred during preseason training.

"We are optimistic that the most recent CARE Consortium research findings will not only arm physicians and scientists with even better data on the prevalence and mechanisms of concussion and head impact exposure outside of regular-season play, but also shed light on the importance of better prevention and protection methods," NCAA Chief Medical Officer Brian Hainline said.

Hainline indicated the study results will be presented to the NCAA Football Oversight Committee at its next meeting in March.

"The Football Oversight Committee is keenly focused on making the sport as safe as possible," said Shane Lyons, West Virginia University director of athletics and committee chair. "We plan to translate important, emerging research data into policies and recommendations that further our focus on football safety." 

While a sport-related concussion is an inherent risk in all contact and collision sports, the NCAA and its Sport Science Institute remain leaders in championing student-athlete well-being.

Launched in 2014, the CARE Consortium involves participants on 30 campuses across the country, including most of the nation's military academies.

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Explaining the NFL's latest concussion controversy and policy change

Becky Sullivan

On Sunday, Miami Dolphins backup quarterback Teddy Bridgewater became the first player to be pulled from a game under the NFL's revised concussion policy. Edward Diller/Getty Images hide caption

On Sunday, Miami Dolphins backup quarterback Teddy Bridgewater became the first player to be pulled from a game under the NFL's revised concussion policy.

The NFL is once again under fire over concussions.

After Miami Dolphins quarterback Tua Tagovailoa sustained a pair of big hits, the second of which left him needing to be carted off the field, the league and its players' union opened an investigation and said it would review its concussion policy.

Over the weekend, the investigation findings were released and the league announced it would change a key element of its concussion policy, effective immediately.

Now, all eyes are watching closely to see how officials handle concussions as the NFL heads into the sixth week of its season.

Looking to catch up on the latest? Read on.

Why's this happening now?

The hits on Tagovailoa sparked the latest concussion conversation.

First, in a Sept. 25 game against the Buffalo Bills, Tagovailoa was pushed to the ground and his head hit the turf. Afterward, he stumbled and needed help steadying himself, leading many viewers to believe he'd been concussed. But he returned to the game after a medical evaluation, and team officials later attributed Tagovailoa's wobbliness to a back injury he'd sustained a few plays earlier.

Dolphins QB Tua Tagovailoa's injury sparks concern over the NFL's concussion policies

Then, four days later, Tagovailoa returned to the field for a Thursday night game against the Cincinnati Bengals. He was sacked and his head hit the turf again; immediately afterward, his fingers and arms were flexed unnaturally in what appeared to be a "fencing response," a telltale sign of traumatic brain injury.

After Tagovailoa's injuries, many viewers – including former players and concussion experts – criticized the decision to allow the quarterback to return to play.

That’s a serious injury . Tua shouldn’t have been out there with Sunday Thursday turn around. Sometimes players need protecting from themselves. Dolphins failed Tua — shannon sharpe (@ShannonSharpe) September 30, 2022

"We are all outraged by what we have seen the last several days and scared for the safety of one of our brothers," said JC Tretter , the president of the NFL Players' Association. "We need to figure out how and why the decisions were made last Sunday to allow a player with a 'no-go' symptom back on the field."

What is the NFL doing about it?

The NFL and its players' union conducted an investigation and released the findings last weekend. The league also announced a change to its concussion policy.

The investigation showed that the NFL's concussion protocol had been followed in evaluating Tagovailoa, who did not show concussion symptoms either during his mid-game medical evaluation on Sept. 25 or in the days that followed before the Thursday game. Instead, Tagovailoa's unsteadiness was attributed to a back injury he'd sustained on an earlier play.

The NFL and players union agreed to an updated concussion protocol

But the league and union also acknowledged that "the outcome in this case was not what was intended" when its concussion protocol was drafted.

Now, the policy has been changed. The revision concerns ataxia, the medical term for the poor muscle control associated with concussions that can appear as unsteadiness or slurred speech. Going forward, any player who is diagnosed with ataxia will not be allowed to return to the game. Previously, players could return if there was another explanation for a moment of instability, like how Tagovailoa's stumble was attributed to the back injury.

The new policy has already come into play: During the Dolphins' game Sunday, an independent certified athletic trainer (also called an "ATC spotter") reported seeing the team's backup quarterback, Teddy Bridgewater, stumble after being hit on the first snap of the game. The report triggered the new clause of the concussion policy, and Bridgewater was pulled from the game. He's now in concussion protocol alongside Tagovailoa.

Is there any connection to this week's controversial "roughing the passer" calls?

For those who didn't watch this past weekend: A pair of questionable "roughing the passer" penalties raised eyebrows and caused some to wonder if the league had asked referees to more strictly penalize quarterback tackles in the wake of the Tagovailoa incident.

Study: CTE Found In Nearly All Donated NFL Player Brains

The first was a Sunday flag against the Atlanta Falcons' Grady Jarrett for tackling Tom Brady of the Tampa Bay Buccaneers. The other came Monday night against the Kansas City Chiefs' Chris Jones, whose strip-sack of Las Vegas Raiders quarterback Derek Carr was overturned by the penalty.

The roughing-the-passer penalty is designed to keep defensive players from tackling quarterbacks in dangerous ways. But many felt the tackles had been appropriate and wondered if there was a connection between the calls and the Tagovailoa incident.

On Tuesday, The Associated Press reported that the NFL had not issued any directive to referees, but that the topic will be discussed next week at a meeting of team owners in New York. (Even if any changes to the rule are proposed, they would be unlikely to take effect until next season.)

"When you do it right, I don't believe you should be punished for it," Jarrett said this week on an Atlanta sports radio program . "Hopefully something can come from this and a change can happen but at the end of the day, I would hope that some conversation would be had."

Shots - Health News

After a concussion, the brain may no longer make sense of sounds.

Statistics show that roughing penalties are down from last season. In 2021, there'd been 54 such penalties through Week 5; this year, there've been only 29.

What does research say about how long players should sit out after a concussion?

Concussion recovery times vary widely. More severe concussions — like the kind that can cause a player to stumble or lose consciousness altogether — take longer to recover from.

Over the weekend, the NFL's top medical official said that players diagnosed with a concussion miss a median time of 9 days.

That's in line with current concussion research. Studies vary, but many have found a "return to play" timeline within that timeframe for elite male athletes like NFL players.

Professional athletes generally have quicker concussion recovery timelines than non-athletes, said Christopher D'Lauro, a cognitive neuroscientist at the Air Force Academy, who called the NFL's nine-day median "a good number."

Repeated Head Hits, Not Just Concussions, May Lead To A Type Of Chronic Brain Damage

In his 2018 study of concussions among cadets at the military academy , D'Lauro and his colleagues found that men returned to play more quickly than women, and "elite athletes" – meaning players on the school's NCAA Division I teams – returned to play more quickly than non-athletes.

The male athletes had the shortest recovery periods, just 20 days, while female non-athletes needed double the recovery time, they found. Women athletes and men who weren't D1 athletes were somewhere in between. (Other studies have found that professional athletes recover even more quickly than college players.)

Several factors help explain the difference in recovery times between NFL players and an average person, D'Lauro said.

For one, even a healthy brain is an energy-intensive organ, and concussions can cause an abnormal increase in brain activity . Athletes are better poised to absorb that energy hit, D'Lauro said. "If you're a normal person and you get a concussion, you don't have much energetic expense capacity to spare when compared with an athlete who is training year-round," he said.

A Concussion Can Lead To Sleep Problems That Last For Years

The other major variable is around-the-clock access to medical care. "They have certified athletic trainers, they have doctors, they have physical therapists who are monitoring them and progressing them through the protocol at an appropriate rate," he said.

Returning to the field too soon after a concussion can be dangerous. Research has shown that people who experience a concussion are more likely to have a future concussion, and some studies of people with multiple concussions have found that the subsequent injuries can cause worse symptoms.

While medical professionals have made major strides in identifying concussions, diagnosis can still be a challenge, D'Lauro added. There is no single test that can unequivocally identify concussions, unlike infections like strep throat. "You go take your kids to the pediatrician, and they do the rapid strep [test], it's like — you're good or you're not," he said. "There's nothing like that for concussions. It's all clinician judgment, so it is pretty hard."

Research shows that even a single concussion is associated with an increased risk of brain disorders like Parkinson's disease and dementia .

And research shows that repeated hits to the head — not just concussions – can increase the risk of developing the degenerative brain condition CTE, which has been found in many former NFL players.

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The Harmful Neurological Effects of Football on the Human Brain

Mar 18, 2021 | Author Asher Levinson , Neurology and Neurosurgery

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NFL Concussions

Football is one of America’s favorite pastimes. A fun, physical sport that millions of fans across the country enjoy. The National Football League (NFL) brings in billions of dollars in revenue, with the Super Bowl having upwards of 92 million viewers in 2021. Though a seemingly carefree and fun sport, as researchers examine more injury data, evidence emerges of serious brain damage stemming from hard hits to players’ heads and resulting concussions. There has been a lot of controversy surrounding the NFL’s handling of the newfound research, from hiding certain information from players and fans to denying the negative effects of the sport altogether.

The main neurological condition that affects these players is chronic traumatic encephalopathy (CTE). CTE is a degenerative brain disease associated with repeated traumatic brain injuries (TBIs), including concussions and repeated blows to the head. Brains with CTE accumulate a protein called tau. The tau clumps together in the brain interrupting critical information flow. CTE takes 8-10 years to manifest, and the symptoms can vary from forgetfulness to violent tendencies and intentions. Unfortunately, CTE can only be diagnosed through autopsies, so it is unclear how many undiagnosed players suffer from the illness. 

Despite this lack of clarity, out of 202 brains of former NFL players that were tested, 177 were diagnosed with CTE. An individual example that demonstrates football’s dangers on the human brain is the story of Aaron Hernandez. Hernandez was a tight end for the New England Patriots for 3 seasons and quickly become a star in the NFL, but his stardom was forgotten when he was arrested and charged with the murder of Odin Lloyd. After committing suicide in his cell, an autopsy revealed an incredibly severe case of CTE. The tragic story of Aaron Hernandez served as an eye-opener to football players and fans, emphasizing the need for more preventative measures and research on CTE.

Although there was clear evidence of the detrimental effects of trauma on the brain, the NFL didn’t acknowledge the issue until 2009 (Iskandar et al., 2018). As recently as seven years ago, one of the NFL’s top concussion specialists, Dr. Ira Casson, denied the correlation between football and brain damage, which incited public uproar that ultimately forced him to step down. Dr. Casson made troubling statements, including saying that there was no evidence supporting a connection between multiple head injuries and long-term neurological problems, concluding in his research study that the “majority” of players examined “had no clinical signs of brain damage.” The paper and study as a whole conducted by Dr. Casson has been completely disregarded and effectively viewed as inaccurate. In response, the NFL has disregarded his research, and in 2018, it reallocated more than $17 million in funding to concussion and brain injury research. 

After the NFL’s support and acknowledgment of the brain injuries endured from football, the number of high school and collegiate football players has dropped dramatically. The NFL has made some positive changes to make the game safer. Players are immediately removed from the field when there’s a potential concussion, and if diagnosed, they can only return to play after completing a 5-step process including rest, exercise, and thorough examination from an independent neurological consultant. They have also banned helmet-to-helmet hits. 

Despite the NFL’s strides in their understanding of the effects of football on the brain, there is still much more research to be done. Even with safer helmets, rules, and regulations, football is a sport that requires consistent human-to-human collisions. Football is always going to be a dangerous game, but hopefully, with time it can become a safer game that won’t have long-lasting implications on people’s brains. 

Bibliography

Swetlitz, Ike, and Bob Tedeschi. “After a public fall, the face of NFL      concussion denial resurfaces.” Stat, 28 Apr. 2016, www.statnews.com/2016/04/      28/concussion-football-ira-casson-science/. Accessed 7 Mar. 2021. 

Tharmaratnam, T., Iskandar, M. A., Tabobondung, T. C., Tobbia, I., Gopee-Ramanan, P., & Tabobondung, T. A. (2018). Chronic Traumatic Encephalopathy in Professional American Football Players: Where Are We Now?. Frontiers in neurology, 9, 445. https://doi.org/10.3389/fneur.2018.00445

Maske, Mark. “NFL allocates more than $17 million to fund research into      concussions and brain health.” The Washington Post, 5 Jan. 2018,      www.washingtonpost.com/news/sports/wp/2018/01/05/      nfl-allocates-more-than-17-million-to-fund-research-into-concussions-and-brain-he      alth/. Accessed 7 Mar. 2021. 

Resnick, Brian. “What a lifetime of playing football can do to the human brain.”      Vox, 1 Feb. 2020, www.vox.com/science-and-health/2018/2/2/16956440/      super-bowl-2020-concussion-symptoms-cte-football-nfl-brain-damage-youth.      Accessed 7 Mar. 2021. 

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Scientists Say Concussions Can Cause a Brain Disease. These Doctors Disagree.

As another major medical institution acknowledged the link between concussions and the brain disease C.T.E., a group of scientists who guide many of sports’ top governing organizations dismissed the research at its conference.

By Ken Belson

AMSTERDAM — For the first time since 2016, one of the most influential groups guiding doctors, trainers and sports leagues on concussions met last month to decide, among other things, if it was time to recognize the causal relationship between repeated head hits and the degenerative brain disease known as C.T.E.

Despite mounting evidence and a highly regarded U.S. government agency recently acknowledging the link , the group all but decided it was not. Leaders of the International Consensus Conference on Concussion in Sport, meeting in Amsterdam, signaled that it would continue its long practice of casting doubt on the connection between the ravages of head trauma and sports.

C.T.E., or chronic traumatic encephalopathy, was first identified in boxers in 1928 and burst into prominence in 2005, when scientists published their posthumous diagnosis of the disease in the N.F.L. Hall of Fame center Mike Webster, creating an existential crisis for sports such as football and rugby that involve players hitting their heads thousands of times a year.

Scientists have spent the past decade analyzing hundreds of brains from athletes and military veterans, and the variable evident in nearly every case of C.T.E. has been their exposure to repeated head trauma. Researchers have also established what they call a dose response between the severity of the C.T.E. and the number of years playing collision sports.

After playing down an association between head injuries and brain damage for years, the N.F.L. in 2016 acknowledged that there was a link between football and degenerative brain disorders such as C.T.E. Just days before the conference in Amsterdam, the National Institutes of Health, the biggest funder of brain research in the United States, said that C.T.E. “is caused in part by repeated traumatic brain injuries.”

But in one of the final sessions of the three-day conference, one of the leaders of the conference, a neuropsychologist who has received $1.5 million in research funding from the N.F.L. , dismissed the work of scientists who have documented C.T.E. in hundreds of athletes and soldiers because he said their studies thus far did not account for other health variables, including heart disease, diabetes and substance abuse.

“To think that there is one factor that is contributing to their current problems and that factor you can see under a microscope after death is an extraordinarily naïve position when you think about the human condition,” said Dr. Grant Iverson, a neuropsychologist at Harvard who ran the session and was a lead writer of the conference’s statement on long-term impacts of repeated head trauma.

A recording of that session obtained by The New York Times, as well as interviews with people who attended, offered a rare glimpse of the fissures among the scientists who set concussion policy in sport, and it revealed reasons for their continued refusal to consider almost all of the new research on long-term impacts of head trauma as they prepare to release guidance for sports leagues around the world.

At the heart of the group’s purpose is its consensus statement, periodically issued concussions guidance agreed upon by most of the group’s several dozen members. It is foundational to the protocols of many of the world’s top pro-sports leagues. Medical advisers to many of those leagues, including the chief medical officers for the N.C.A.A. and World Rugby, helped craft that statement in Amsterdam. The newest iteration was expected to be released in 2023.

But the makeup of the group itself poses apparent conflicts of interest that call into question their delay on accepting new research on concussions. FIFA; the I.O.C.; the F.I.A., which governs automobile racing leagues including Formula One; World Rugby; and other governing organizations in sports sponsor the conference and have working relationships with many of the leaders of the conference or provide them with research funding.

“This group has been led by people who don’t really have a full understanding of the pathology of head injury at that level,” said Willie Stewart, a neuropathologist in Glasgow who has diagnosed C.T.E. in many athletes. He said the conference leaders should have their terms limited. “There should be a rotation of people so they don’t have any fear of what they said four years ago.”

Previous consensus statements claimed that the science was not settled on C.T.E., and that language has been adopted by sports leagues including the N.H.L., the N.C.A.A. and New Zealand Rugby, a stamp of approval from scientists that has helped some of those organizations fend off lawsuits accusing them of hiding the dangers of concussions from athletes.

Still, researchers pushing for a recognition of a cause-and-effect relationship between head trauma and C.T.E. were initially optimistic that the group’s leaders might be swayed by new research. In March, Paul McCrory, a longtime leader of the group and a vocal skeptic of the links between head hits and C.T.E., resigned after he was caught plagiarizing .

But in conversations before and during the conference, leaders of the group centered their discussions on what was unknown about C.T.E., noting that it was unclear why some athletes got the disease and others who played the same sport did not. No one can say how much head trauma is needed to get C.T.E. A reliable test for diagnosing the disease in the living is at least five years off, experts said.

Then, in one of the conference’s final sessions, titled “Long Term Sequellae and Criteria for Retirement,” Iverson began the hourlong confab by discussing the criteria the group would use to review concussions research.

Of the nearly 7,500 papers on concussions that the group identified, the writers of the consensus statement considered only 26, which did not include any of the major research papers on C.T.E.

Dr. Ann McKee, a neuropathologist at Boston University who is the world’s leading C.T.E. expert, pulled out of the conference because she was told her work would not be fully integrated into the statement.

Jon Patricios, Bob Cantu, Mike McNamee and Kathryn Schneider, the leaders of the conference, said in an email that some research on C.T.E. that was excluded from the formal review was still presented at the session so that “a spectrum of views” could be heard. They added that they were unable to share specifics on which were included.

Iverson described the limitations of the existing research and why much of it was excluded from consideration. Most C.T.E. research, he explained, considered only one or two variables, like age and sex, but not others, like heart disease, diabetes and alcohol abuse.

Because the disease can only be diagnosed posthumously, scientists have not yet created long-term studies which follow living subjects through their lives as some are exposed to brain trauma and others are not. In that scenario, scientists would need to solicit brains from people who did not compete in collision sports and would not know the results of the study until after the participants had died.

“If we think about the importance of later-in-life brain health, these are some variables that are important to consider,” Iverson said.

Some who attended the session were unconvinced that the lack of such research mitigated the avalanche of studies that establish a causal relationship between brain trauma and C.T.E.

“To do the types of studies they want to include in this way will take decades,” said Michael Grey, who teaches rehabilitation neuroscience at the University of East Anglia in England. “Are we supposed to wait decades and have tens of thousands of people suffer from neurodegeneration when we could be doing something about it now?”

A conference rule allows just 7 of the 29 writers to block language in the statement, potentially creating another barrier to the group agreeing to phrasing that links head trauma to C.T.E. The consensus-statement writers include many doctors who do not specialize in degenerative brain disease yet advise the N.H.L., Australian Football League and other leagues.

Cantu, one of the foremost researchers on C.T.E., followed Iverson with a 15-minute presentation in which he told the group that it had “kicked down the road” the issue of C.T.E. in their last two consensus statements, published in 2013 and 2017. He said that the cognitive, behavioral and mood issues associated with C.T.E. overlap with many other diseases, which make it hard to diagnose clinically.

But since 2016, he said there have been more than 100 papers a year published on C.T.E., including one he co-wrote this year with Chris Nowinski, a Ph.D. in behavioral neuroscience who co-founded the nonprofit Concussion Legacy Foundation, and other researchers. In it, they detailed their findings that there existed a high probability that repeated head trauma causes C.T.E. Their paper, he said, helped convince the N.I.H. to change its stance.

Nowinski and his colleague from the Concussion Legacy Foundation, Adam White, taunted the leaders of the conference by holding satirical drawings as they arrived.

Their posters featured smiling doctors in lab coats holding cigarettes, with “Enjoy repetitive head impacts” and “Don’t worry about CTE!” a parody of advertising in the 1940s and 1950s in which doctors promoted smoking.

“I’m there to remind them that if they don’t acknowledge a cause-and-effect relationship, a lot more people are going to get hurt and it’s going to ruin their reputations,” Nowinski said. “The problem is, if they say cause-and-effect is established, it will cost the organizers of the conference a lot of money in lawsuits.”

Ken Belson covers the N.F.L. He joined the Sports section in 2009 after stints in Metro and Business. From 2001 to 2004, he wrote about Japan in the Tokyo bureau. More about Ken Belson

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Youth Tackle Football: Perception and Reality

POTENTIAL CONFLICT OF INTEREST: Dr LaBella is chairperson for the American Academy of Pediatrics Council on Sports Medicine and Fitness; she serves as an American Academy of Pediatrics representative to the medical advisory committees for Pop Warner Little Scholars and US Soccer. She also serves on the Illinois High School Association Sports Medicine Advisory Committee. Dr LaBella does not receive any funding from these organizations.

FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose.

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Cynthia LaBella; Youth Tackle Football: Perception and Reality. Pediatrics May 2019; 143 (5): e20190519. 10.1542/peds.2019-0519

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Recently there has been significant media attention on sports-related concussions, particularly in American football. The focus has been on the risk for long-term negative health outcomes from concussions and subconcussive head impacts that may be sustained while participating in contact sports, especially for young athletes whose brains are still developing. 1 In this issue of Pediatrics , Chrisman et al 2 present results of their study, “Parents’ Perspectives Regarding Age Restrictions for Tackling in Youth Football,” in which they surveyed a nationally representative sample of ∼1000 parents regarding their perception of concussion risk in youth tackle football and whether they would support age restrictions for tackling. Most parents (61%) would support such an age restriction, and those who are female, college-educated, or reported greater perceived risk for concussion had a higher odds of supporting an age restriction. The most notable finding of this study, however, is that most parents perceive concussion rates in tackle football to be substantially higher than they actually are. The best available and most current injury surveillance data for tackle football players reveal that ∼4 to 7 out of 100 high school players will suffer a concussion during a single season. 3 , 4 For youth players, the incidence tends to be lower at 3 to 5 in 100. 3 , 5 , 6 However, 83% of parents in this study perceive concussion incidence to be >10 out of 100 high school tackle football players, and 25% estimated it was >50 out of 100. This misperception about concussion risk in youth tackle football is likely due to the fact that most parents form their views on the basis of headlines and stories of former players in the media, rather than from published scientific data.

The reality is that the concussion rate in youth tackle football is lower than parents perceive (3%–5% of players per season) and is similar to concussion rates in other youth contact sports, such as soccer, ice hockey, lacrosse, and even flag football. 3 , 5 , – 12 In contact sports, rates of overall injury and concussion increase uniformly with age and pubertal maturation status. 3 , 5 , 9 , 12 , – 21 This is because as bodies get larger and faster, collisions occur with greater force. 22 , 23 Thus, concussion risk in tackle football is lowest when players are <12 or 13 years of age, before the pubertal growth spurt begins.

What about the effect of tackling and subconcussive head impacts on young developing brains, even in the absence of injury? Unfortunately, the evidence on long-term outcomes is unclear. There are few studies, and they reveal conflicting results. Alosco et al 24 administered telephone-based cognitive function tests and online surveys of behavioral and/or emotional symptoms to 214 former high school, collegiate, and professional football players in their 40s and 50s. Their data suggest that exposure to tackle football before 12 years of age is associated with cognitive impairment and depression later in life. 24 This study received widespread media coverage, which has led to significant public concern about the safety of youth tackle football. However, as is often the case with news reports on scientific studies, headlines tend to be sensationalized and key details are omitted. There are several limitations that prevent the generalization of this study’s findings to the broader population of tackle football players. It was not a random sample. Volunteers were recruited through Web site postings, creating selection bias for those experiencing symptoms. Subjects were asked about events during their childhood, so recall bias may have led to inaccurate reporting. The analysis did not account for the number of previous concussions. However, the group who started football before age 12 reported significantly more concussions than those who started at age 12 or older (median of 25 vs 15, respectively). This is likely the factor driving the difference between the 2 groups. Players did not indicate how many, if any, of their concussions occurred during participation in youth football. The study did not include men who only played football at the youth level and did not go on to play in high school, college, or in a professional league. There was no comparison with a control group of male peers who had never played football. It did not account for factors such as family history, substance use, and lifestyle, which are known to influence mood disorders and cognitive function. The authors highlight these limitations as reasons why their study’s findings “should not be used to inform safety and/or policy decisions in regards to youth football.” They indicate that longitudinal studies are needed to understand the long-term health effects of playing youth tackle football.

Authors of a larger, prospective study followed 3904 high school students into their 60s and 70s and compared the 834 who played football to 1858 who played noncontact sports or no sports, matching football players to the other 2 groups on the basis of age, IQ, family background, and educational level. They found no differences in cognitive function or depression when comparing football athletes to noncontact sport athletes and to nonathletes. 25 Football players, however, were more likely to engage in regular moderate-to-vigorous physical activity at 35 years of age. This study has some limitations as well. The authors did not account for concussion history, position played, or exposure to football before or after high school. The study also did not make any headlines. So the public does not get a balanced report of the research. But even for those of us with a balanced view, how do we resolve the conflicting results of these studies? From these limited data, it seems a small subset of mostly collegiate and professional football players may develop long-term impairments, whereas most do not. As with many other medical conditions, intrinsic factors likely influence long-term outcomes on an individual level. One of these factors is likely the number of concussions sustained, especially those that are inadequately treated.

An important limitation of both of these studies share is that all the subjects played football many years ago during an era when concussions often went unrecognized and untreated, and rules of the game were different than they are today. This makes it difficult to extrapolate their findings to the current generation of youth football athletes. Decades ago, athletes frequently continued to play with concussion symptoms, which were likely compounded with repeated subsequent impacts. We now know that repeated concussions within a short time frame, before the first concussion has resolved, typically lead to more severe and prolonged symptoms. Currently, the standard of care is for concussed athletes to be removed from contact sports until they are completely recovered and have received clearance from a qualified health care professional to return to play. Additionally, concussion awareness has significantly increased in the past decade, so athletes are much more likely to report symptoms and seek care than in the past.

Football culture and rules have also changed since the men in these 2 studies played. For example, spear tackling and other unsafe tackling and blocking techniques are no longer allowed. At the youth level, full contact is limited to ≤25% of practice time, and coaches must complete annual training in concussion recognition and how to teach proper tackling and blocking techniques. This type of coach education and practice contact restrictions have decreased injury rates and head impacts. 26 , 27 More recently, Pop Warner Football eliminated kick-off returns for players under age 12 to reduce the number of higher-speed collisions. It also banned the 3-point stance for players under age 11 to reduce repetitive head impacts with blocking. As Chrisman et al 2 noted, age restrictions for tackling have also been proposed to reduce tackling-related injuries in the youngest players.

A number of longitudinal studies are ongoing to measure health outcomes of tackle football athletes who are playing in this current era of new rules and improved concussion awareness and management. One was just published in which authors examined 3462 collegiate football athletes from 2014 to 2018. There were no differences in neurocognitive function between those who started playing football before versus after age 12, even after adjusting for age, learning accommodations, and concussion history. 28  

Rules will continue to evolve as scientists, policy makers, and youth sports governing bodies work together to objectively evaluate the growing body of research, accounting for quality and limitations of each study, in an effort to make targeted changes to enhance the safety of tackle football at all levels of play. As physicians, we can help parents interpret the research and provide them with the information that is missing from the headlines.

Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER : A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2018-2402 .

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High school football concussions and long-term health concerns: Research roundup

Growing concern about concussions is unsettling high school football communities. We round up the recent findings.

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This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License .

by David Trilling, The Journalist's Resource October 20, 2017

This <a target="_blank" href="https://journalistsresource.org/education/high-school-football-injuries-concussions-research/">article</a> first appeared on <a target="_blank" href="https://journalistsresource.org">The Journalist's Resource</a> and is republished here under a Creative Commons license.<img src="https://journalistsresource.org/wp-content/uploads/2020/11/cropped-jr-favicon-150x150.png" style="width:1em;height:1em;margin-left:10px;">

For many Americans, football is quintessential to the high school experience. But researchers have begun to worry about long-term risks from the violent blows and concussions players receive on the field. Many questions remain unanswered, but the findings are so serious that some former players are calling for a ban on the sport.

Football players are not the only athletes who face risks, of course. Hockey, lacrosse and other sports can also lead to head injuries. But tackle football is the most popular high school sport in America, with over 1 million participants a year, according to the National Federation of State High School Associations, an intramural rules-making body.

And football players suffer more concussions than any other high school athletes, according to a 2017 study in the Journal of Athletic Training . During a game, football players are 16 times more likely to suffer a concussion than baseball players and four times more than male basketball players. (For girls, the study found soccer to be the most dangerous high school sport, followed by lacrosse.) According to the Centers for Disease Control and Prevention (CDC), 2.4 high school football players die per year due to traumatic head injuries.

A concussion is a type of brain injury that often results in a temporary loss of consciousness. According to the National Institutes of Health, a concussion “happens when a hit to the head or body causes your head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in your brain. Sometimes it can also stretch and damage your brain cells.” A 2017 paper in the Annals of Neurology finds that a concussion in adolescence is associated with a higher risk of developing  multiple sclerosis later.

Repeated concussions may cause chronic traumatic encephalopathy (CTE), a neurodegenerative disease that can only be diagnosed during an autopsy, and which has been associated with memory loss and depression in former football players. Post-concussion syndrome and traumatic brain injury (a severe concussion) are related conditions. Former New England Patriots player Aaron Hernandez, who killed himself in 2017 at age 27 while serving time for murder, was found after his death to have had a severe case of CTE. A 2017 study in the Journal of the American Medical Association (JAMA) found evidence of CTE in 110 of 111 deceased National Football League players. (That study has been criticized because the brains were donated by family members concerned about their deceased loved one’s health; the findings may not be representative of all football players.)

Yet a longitudinal 2017 study of almost 4,000 high school football players finds no relationship between playing football and cognition or mental health later in life, when the men were 65. This study, likewise published in JAMA , also stressed the trade offs — that sportiness has health benefits: Men who had played football in high school were more physically active at age 35 than non-players.

Many questions remain. Could the risks of football be growing? Players these days are bigger and stronger than they were in the 1950s and ‘60s, according to a 2017 study in the Mayo Clinic Proceedings . But protective gear today is more sophisticated (though a poorly fitting helmet can increase the severity of concussions).

Then again, some researchers have suggested that better gear could be changing how the game is played, causing players to “lead with their heads,” increasing their chances of a concussion. The CDC has also raised that concern.

More research is needed. With a million young men actively engaged on the field, football’s risks are bound to attract attention. The peer-reviewed research cited below includes some of the latest findings.

• Collins, Christy L.; et al. “Concussion Characteristics in High School Football by Helmet Age/Recondition Status, Manufacturer, and Model.” The American Journal of Sports Medicine , 2016. DOI: 10.1177/0363546516629626.
• Deshpande, Sameer; et al. “Association of Playing High School Football With Cognition and Mental Health Later in Life.” Journal of the American Medical Association , 2017. DOI: 10.1001/jamaneurol.2017.1317.
• Greenhill, Dustin; et al. “Inadequate Helmet Fit Increases Concussion Severity in American High School Football Players.” Sports Health , 2016. DOI: 10.1177/1941738116639027.
• Janssen, Pieter; et al. “High School Football and Late-Life Risk of Neurodegenerative Syndromes, 1956-1970.” Mayo Clinic Proceedings , 2017. DOI: 10.1016/j.mayocp.2016.09.004.
• Kucera, Kristen L.; et al. “Traumatic Brain and Spinal Cord Fatalities Among High School and College Football Players — United States, 2005-2014.” Morbidity and Mortality Weekly Report , 2017. DOI: 10.15585/mmwr.mm6552a2.
• Mez, Jesse; et al. “Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football.” Journal of the American Medical Association , 2017. DOI: 10.1001/jama.2017.8334.
• Montgomery, Scott; et al. “Concussion in Adolescence and Risk of Multiple Sclerosis.” Annals of Neurology , 2017. DOI: 10.1002/ana.25036.
• O’Connor, Kathryn L.; et al. “Epidemiology of Sport-Related Concussions in High School Athletes: National Athletic Treatment, Injury and Outcomes Network (NATION), 2011–2012 Through 2013–2014.” Journal of Athletic Training , 2017. DOI: 10.4085/1062-6050-52.1.15.
• Weihong, Yuan; et al. “Neck Collar with Mild Jugular Vein Compression Ameliorates Brain Activation Changes During a Working Memory Task After a Season of High School Football.” Journal of Neurotrauma , 2017. DOI: 10.1089/neu.2016.4834.

About The Author

David Trilling

• Concussions and Cognitive Performance

Former NFL players study shows concussion impacts decades after retirement.

Former professional football players who reported experiencing concussion symptoms during their playing careers were found to perform worse on a battery of cognitive tests than nonplayers, according to a study led by Harvard Medical School investigators at Massachusetts General Hospital, Brigham and Women’s Hospital, McLean Hospital, and Spaulding Rehabilitation Hospital.

Results of the study were published March 2 in Archives of Clinical Neuropsychology .

Of the more than 350 former National Football League players who were studied as part of the Football Players Health Study at Harvard University an average of 29 years after their playing careers ended, those who reported experiencing concussion symptoms during their careers scored worse on assessments of episodic memory, sustained attention, processing speed, and vocabulary.

The number of concussions diagnosed by a medical professional or length of playing career, however, had no observed effect on cognition.

A follow-up analysis compared the former players to more than 5,000 male volunteers in the general population who did not play professional football, which found that cognitive performance was generally worse for former players than nonplayers.

While younger former players outperformed nonplayers on some tests, older retired players were more likely to perform worse than controls on cognitive tasks.

The researchers who led the study said that their results underline the importance of tracking concussion symptoms, as opposed to diagnosed concussions, in research.

This work also adds evidence to the impact a professional football career can have on accelerating cognitive aging.

“It is well established that in the hours and days after a concussion, people experience some cognitive impairment. However, when you look decades out, the data on the long-term impact have been mixed,” said study senior author Laura Germine , an associate professor of psychiatry at HMS and director of the Laboratory for Brain and Cognitive Health Technology at McLean.

“These new findings from the largest study of its kind show that professional football players can still experience cognitive difficulties associated with head injuries decades after they have retired from the sport,” Germine said.

Concussion symptoms linked to cognitive performance

For the study, 353 retired NFL players completed hour-long neuropsychological tests through an online platform called TestMyBrain, supported by McLean and HMS.

Players were fully remote and completed tests on a laptop or desktop that included assessments that measured processing speed, visual-spatial and working memory, and aspects of short- and long-term memory and vocabulary.

Recollected concussion symptoms were measured by asking the players the number of times they experienced any one of the following symptoms after receiving a blow to the head during play or practice: headaches, nausea, dizziness, loss of consciousness, memory problems, disorientation, confusion, seizure, visual problems, or feeling unsteady on their feet.

They were also asked whether they lost consciousness during their careers, and whether they were ever diagnosed with a concussion by a medical professional.

The results showed that the former players’ cognitive performance was associated with recalled football concussion symptoms.

For example, differences observed in visual memory scores between former players with the highest and lowest reported concussion symptoms were equivalent to the differences in cognitive performance between a typically healthy 35-year-old and a typically healthy 60-year-old.

However, poor cognitive performance was not associated with diagnosed concussions, years of professional play, or age of first football exposure.

The researchers noted that many head injuries or sub-concussive blows may not have been diagnosed as concussions due to a lack of awareness at the time or underreporting of symptoms by players.

When comparing the retired players to a group of 5,086 men who did not play football, cognitive performance was generally worse for former players.

On two tests of processing speed, age-related differences in cognitive performance were greater among the former player group than the nonplayer group, with older players performing worse.

These comparison data suggest that football exposure might accelerate age-related cognitive declines and produce greater disadvantages at older ages, according to the researchers, who added that more studies are needed to track cognitive performance in former players as they age.

Another possibility is that improved awareness and management of head injuries may have spared younger retired players more than older ones.

The researchers also noted that this comparative finding is limited by a lack of data on cognition prior to head injuries, and that more research is needed that closely matches former players and nonplayers and measures their cognitive performance across their lifetimes.

“For both former players and researchers, we can glean some important takeaways from this study,” said principal investigator Ross Zafonte of the Football Players Health Study at Harvard University.

“Former players can support their cognitive health as they age by taking proactive steps and continuing to consult with their providers and educate themselves on symptoms of head injury. For researchers and providers, these findings support efforts to develop ways to enhance diagnosis and define long-term sequelae of concussion,” he said.

Zafonte is the Earle P. and Ida S. Charlton Professor and chair of the HMS Clinical Department of Physical Medicine and Rehabilitation, president of Spaulding Rehabilitation Network, and a sports medicine physician.

“The Community Based Participatory Research (CBPR) approach taken in this study is where this field is heading,” said Germine. “We are grateful to the players and how much they have taught us. It would not have been possible to do a study like this without engaging and deeply involving their community.” Research driven by input from former NFL players

The Football Players Health Study, launched in 2014, is a comprehensive research program dedicated to examining the multifactorial causes that impact the health of former NFL players.

The research has been informed by the players themselves, who have provided input on the health concerns and conditions they face after a career in football.

An interdisciplinary team of researchers from Harvard University and HMS and its affiliated teaching hospitals, including those in the Mass General Brigham system, conduct research in neurology, cardiology, sports medicine, rehabilitation medicine, chronic pain, and public health.

While concussion and head injury are of paramount concern, the study examines all aspects of player health across the life span.

Former players can find important resources to support their health in this section of the study’s website.

Authorship, funding, disclosures

This work was supported by the Football Players Health Study at Harvard University, funded by the National Football League Players Association (NFLPA).

The content is solely the responsibility of the authors and does not necessarily represent the official views of HMS, Harvard University, and its affiliated academic medical centers.

The NFLPA had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.

Additional co-authors on the study included Roger Strong, Rachel Grashow, Andrea Roberts, Eliza Passell, Luke Scheuer, Douglas Terry, Sarah Cohan, Alvaro Pascual-Leone, and Marc Weisskopf.

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• v.10(1); 2022 Jan

Incidence and Severity of Concussions Among Young Soccer Players Based on Age, Sex, and Player Position

Alden r. weiner.

† Neurosurgery Department, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

John R. Durbin

Susie r. lunardi.

‡ Concussion Management of New York, New York, New York, USA.

Theodore C. Hannah

Alexander j. schupper, jonathan s. gal.

§ Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Oranicha Jumreornvong

Zachary spiera, muhammad ali, naoum fares marayati, alex gometz, mark r. lovell.

∥ Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.

Tanvir F. Choudhri

Background:.

Previously studied risk factors for sports-related concussion in soccer players include sex, age, and player position. However, prior studies were limited in number, they reported conflicting results, and most did not assess initial concussion severity.

Purpose/Hypothesis:

The purpose of this study was to conduct an in-depth analysis of soccer players across key demographic groups (sex, age, position) for both concussion incidence and severity. It was hypothesized that concussion incidence and severity would be higher among male players, players aged ≥17 years, and goalkeepers.

Study Design:

Cohort study; Level of evidence, 3.

The authors analyzed baseline and postinjury ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) scores for athletes aged 12 to 22 years between July 2009 and June 2019. Players were assigned to an age group based on when they had their most recent baseline test. Concussion incidence and concussion severity index were compared using t tests and multivariate logistic regression.

For 1189 individuals who reported soccer as their primary sport, 1032 contributed 1754 baseline ImPACT tests (some individuals had multiple baseline tests), whereas 445 individuals were suspected of sustaining a concussion and then referred for a postinjury 1 test. Of these players, 254 (24.6%) had both a baseline and a postinjury test and were analyzed for concussion severity. Linear regression showed that forwards had a lower incidence of ImPACT-proxied concussions than goalkeepers had ( P = .008). Female players had a significantly higher incidence of ImPACT concussions compared with male players (mean, 0.07 [female] vs 0.04 [male] concussions per person-year; P = .05). Players in the ≥17-year age group had a higher incidence of ImPACT concussions than players in the 15- to 16-year age group ( P = .04), although the 15- to 16-year age group had more severe concussions than the ≥17-year age group (mean severity index, 2.91 [age 15-16 years] vs 1.73 [age ≥17 years]; P = .001).

Conclusion:

Female soccer players experienced a higher incidence of concussion than did male players, and goalkeepers experienced a greater incidence of ImPACT concussions than did forwards. Players of both sexes and all positions in the 15- to 16-year age group showed increased initial concussion severity compared with the ≥17-year age group, despite a lower comparative incidence of ImPACT concussions. Further study is needed to understand whether sex and player position affect concussion severity.

With 7.94 million high school athletes (3.40 million female participants) registered in the 2018-2019 season across 19,500 schools, the necessity for safety evaluations and head injury research for youth in sports remains a priority of parents and coaches in the United States. 18 , 27 The majority of the current research on head injuries in sports has been focused on American football, and although football continues to be the leading sport for high school male participation, soccer was observed as the sport with the largest gain in new participants from the previous year. 18 In addition to having an increasing number of participants, soccer is one of the leading sports in terms of concussion incidence, 8 which warrants specific research into how different groups, particularly sex, age, and position, are affected.

Consensus is lacking regarding head injury prevalence by sex in soccer 2 : Some analyses 6 – 9 , 12 , 15 , 22 , 25 , 28 have reported that female players had a higher concussion incidence rate than male players had, whereas other studies 11 , 28 have reported no significant differences between sexes. Research 8 , 9 , 12 , 15 , 22 , 25 looking at sex-based differences across other sports primarily has found that female players had a greater concussion incidence rate than male players had. Soccer studies that evaluated age and head injury have reported that high school athletes took longer to recover after a concussion compared with collegiate athletes 9 , 19 , 24 yet collegiate athletes had a greater occurrence of concussions compared with high school athletes. 12 , 17 , 25 The research evaluating soccer head injuries by position is more limited in terms of quantity of studies, and a variety of results have been reported regarding the highest concussion incidence: One study reported that defenders had the greatest risk, 2 another reported forwards, 26 and 2 other studies reported goalkeepers. 9 , 10

The purpose of this study was to conduct an in-depth analysis of soccer players across these 3 key demographic groups (sex, age, position) for both concussion incidence and severity. Our objectives were to improve the understanding of injury risk and potentially contribute to future prevention against head injury in soccer. The authors hypothesized that concussion incidence and severity would be higher among male players, players aged ≥17 years, and goalkeepers.

This study received approval from our institutional review board. The study was deemed exempt from informed consent because the data were deidentified and previously collected for clinical use.

Data Collection

A total of 25,815 baseline and postinjury ImPACT 14 (Immediate Post-Concussion Assessment and Cognitive Testing) tests (ImPACT Applications Inc) were conducted between July 1, 2009, and June 30, 2019, and 2434 of these tests reported soccer as the primary sport. The baseline and postinjury ImPACT tests among the soccer players were collected between February 2010 and May 2019, a period of 9 years and 3 months. Data were primarily collected for medical care, and the concussion centers had agreements with ImPACT Applications Inc that allowed the data to be repurposed for research.

Although this was a retrospective study, the criteria for athletes who received ImPACT testing were determined prospectively. Eligible participants aged 12 to 22 years were part of athletic organizations following standardized care, which included preseason baseline testing, same-day head injury assessment by physicians and athletic trainers at sites of injury, and postinjury ImPACT testing for athletes with symptoms consistent with suspected concussions. Follow-up postinjury ImPACT tests were conducted at different intervals depending on symptom severity and student availability. Physicians were employed by high schools and had backgrounds in family medicine and/or physical medicine and rehabilitation. Athletic trainers performed initial postinjury assessments if physicians were not available.

Concussion was defined as blunt trauma to the head followed by either the sudden alteration of mental status or the appearance of multiple pathological symptoms, including headaches, nausea, vomiting, dizziness, and vision problems. All athletes with symptoms consistent with a suspected concussion underwent ImPACT testing. An athlete’s performance on the ImPACT test was used to calculate a severity index, a measurement of the intensity of an athlete’s concussion symptoms.

Patient Information and Medical History

Patient information and medical history were self-reported during ImPACT testing. Patient data included age, sex, and sport played. For incidence calculations, players were assigned to an age group based on their age when they had their most recent baseline test. In most cases, this was less than a year before injury. Sensitivity analysis was performed by removing the observations for players more than a year from baseline; because this did not significantly alter results, the original analysis is reported. Sports were categorized into contact/collision, limited contact, and noncontact sports based on the amount of physical contact and number of collisions between players. 18 Medical history data included diagnosed attention-deficit/hyperactivity disorder (ADHD), diagnosed learning disability, autism, dyslexia, depression, anxiety, chronic headaches, chronic migraines, previous concussion history, and altitude.

ImPACT Testing

As previously described, ImPACT-proxied concussions are defined as significant deviations from baseline tests in at least 2 of the 5 subscores (Verbal Memory, Visual Memory, Processing Speed, Reaction Time, and Symptom Score). Significant deviation is defined as a raw subscore differential greater than the 80% confidence intervals (CIs) of controls, as established by ImPACT guidelines. 14

Concussion Incidence

A head injury is considered to be a suspected concussion when an athlete receives a postinjury ImPACT test. A suspected concussion is an ImPACT concussion when the postinjury ImPACT test has significant deviations from baseline. Incidences of both suspected concussions and concussions as proxied via the ImPACT test were calculated with person-years at risk. ImPACT tests are considered stable and relevant for 2 years, allowing comparison with postinjury tests; therefore, participants exceeding that period of time between baseline tests were considered lost to follow-up. 3 , 4 , 21 Per the US Centers for Disease Control and Prevention, participants lost to follow-up were assigned 1 person-year. 5

Severity Index

A severity index was calculated to assess concussion severity, as previously described. 13 For severity calculations, players were assigned the age of the first postinjury test. Changes in composite scores (▵ Score ) from baseline to postinjury 1 test were calculated (Equation 1). If ▵ Score did not exceed the statistically significant difference ( S diff ), it was assumed that there was no change from baseline (Equation 2). To estimate the severity of each head injury, we summed the number of S diff values above baseline for each composite score to create a severity index (Equation 3).

Statistical Analysis

We used t tests to compare means between continuous variables and rates with 2 categories. Person-years at risk was the time a participant had a valid baseline test but not a postinjury test indicating concussion. Weighted by person-years at risk for concussion incidence but unweighted for severity analysis, simple linear regression was used to compare continuous dependent variables with categorical subsets. Multivariate logistic regression was used to calculate the odds ratios (ORs) of suspected concussions, ImPACT-proxied concussions, and severity among both suspected concussions and ImPACT concussions while controlling for demographic variables. For logistic regression, severity was dichotomized into severity ≤8 and >8. All statistical analyses were performed using SAS (Version 9.4 for Windows; SAS Institute Inc); for all analyses, α = .05.

For ImPACT tests reporting soccer as the primary sport, 1032 individuals contributed 1754 baseline ImPACT tests (some individuals had multiple baseline tests), whereas 445 individuals were suspected of sustaining a concussion and then referred for a postinjury 1 test. A total of 254 (57.1%) individuals with a postinjury ImPACT test had a corresponding previous baseline test and were included in the analysis. Although baseline ImPACT tests were available, some participants did not have a baseline assessment before injury and thus were excluded from analysis.

Of the 1032 individuals with a baseline ImPACT test, 463 (44.86%) were men and 569 (55.14%) were women. There were 316 (30.62%) players aged 12 to 14 years, 479 (46.41%) aged 15 to 16 years, and 237 (22.97%) aged ≥17 years. Player position was available for 795 (77.03%) individuals: 88 (8.53%) were goalkeepers, 270 (26.16%) were defenders, 265 (25.68%) were midfielders, and 172 (16.67%) were forwards. In addition, 44 (4.26%) were diagnosed with ADHD, 29 (2.81%) had a diagnosed learning disability, 2 (0.19%) had autism, 28 (2.71%) had dyslexia, 128 (12.4%) were receiving headache treatment, 95 (9.21%) were receiving migraine treatment, and 284 (27.52%) had at least 1 previous concussion.

All 1032 players with a baseline test were analyzed for concussion incidence. When weighted by the number of person-years in the dataset, the incidence rate was 0.2095 suspected concussions per person-year. The total number of ImPACT concussions was 86. After total concussions were weighted by the number of person-years in the dataset, the resulting incidence rate was 0.0472 ImPACT concussions per person-year.

Concussion Severity

When ImPACT concussion severity was analyzed, only the 254 players with both a baseline and postinjury test were analyzed for sex and age comparisons. All 86 players who sustained an ImPACT-proxied concussion were analyzed for concussion severity. Of the 254 players sustaining a documented suspected concussion with a concomitant baseline, 215 (84.65%) had a corresponding player position and were analyzed when comparing severity across player positions. Of the 86 players with an ImPACT concussion, 75 (87.21%) had a corresponding position and were analyzed for association between severity and position.

When the number of ImPACT concussions each player had was weighted by the number of person-years that the player contributed to the study, a statistically significant difference was seen between sexes in incidence of ImPACT concussions, with female players having a greater incidence than male players (mean incidence, 0.07 ± 0.35 [females] vs 0.04 ± 0.21 [males] concussions per person-year; P = .05). No significant differences were seen between sexes in the incidence of suspected concussions or the severity index ( Table 1 ).

Concussion Incidence and Severity Index by Sex a

a Data are shown as mean ± SD unless otherwise indicated. Bolded P value indicates statistically significant difference between male players and female players ( P < .05, t test).

b ImPACT concussions are defined by significant deviation from baseline scores on a postinjury ImPACT test.

c Severity index indicates concussion severity on a postinjury ImPACT test as proxied by significant changes from baseline.

Overall, the results showed mixed correlations between age and the number of ImPACT concussions, suspected concussions, and severity index ( Table 2 ). After weighting the number of ImPACT concussions by the number of person-years of each group, we noted a statistically significant difference in incidence of ImPACT concussions between the age groups ≥17 years and 15 to 16 years (coefficient = 0.034; P = .040). The numbers of suspected concussions were also compared across the different age groups, and the differences were not statistically significant. However, the older age groups had a greater mean incidence of suspected concussions. We noted a statistically significant difference in mean severity index between the age groups 15 to 16 years and ≥17 years (coefficient = –1.293; P = .001) ( Table 2 ).

Incidence of Concussion and Severity Index by Age Group a

a  Data are shown as mean ± SD unless otherwise indicated. Bolded P values indicate statistically significant difference between age groups as indicated ( P < .05). Beta coefficients significantly different than zero indicate associations between age group and the dependent variable of interest. The age category of 15-16 years was chosen as the reference.

b Calculated using weighted simple linear regression for concussion incidence and simple linear regression for severity index.

c Age 12-14 vs 15-16 years.

d Age ≥17 vs 15-16 years.

Linear regression analysis showed almost no statistically significant differences in the incidence of ImPACT concussions and suspected concussions across the 4 positions, with the exception that forwards had a lower incidence of ImPACT concussions compared with goalkeepers (mean, 0.03 ± 0.21 vs 0.09 ± 0.26 concussions per person-year, respectively; P = .008). The data showed that forwards had the lowest incidence of ImPACT concussions (mean, 0.03 concussions per person-year) as well as suspected concussions (mean, 0.27 concussions per person-year) ( Table 3 ). When goalkeepers and non-goalkeepers were compared, no significant differences were seen in ImPACT or suspected concussions between the 2 groups ( Table 4 ).

Incidence of Concussion and Severity Index by Player Position a

a Data are shown as mean ± SD unless otherwise indicated. Bolded P value indicates statistically significant difference between player positions as indicated ( P < .05). Beta coefficients significantly different from zero indicate associations between player position and the dependent variable of interest. The position of goalkeeper was chosen as the reference.

c Defenders vs goalkeepers.

d Midfielders vs goalkeepers.

e Forwards vs goalkeepers.

Incidence of Concussion and Severity Index: Goalkeepers vs Non-Goalkeepers a

a Data are shown as mean ± SD unless otherwise indicated.

When analyzing concussion severity using severity index, we found no statistically significant differences across the 4 positions ( Table 3 ). Goalkeepers had the highest mean severity index (4.14), whereas defenders had the lowest (1.97). As well, we found no statistically significant differences between goalkeepers and non-goalkeepers in terms of mean severity index ( Table 4 ).

Multivariate Logistic Regression Analysis

The results of the multivariate logistic regression analysis are presented in Table 5 . With male sex as the reference, multivariate analysis did not reveal any significant sex-based difference in suspected concussions ( P = .406), ImPACT concussions ( P = .101), suspected concussion severity ( P = .741), or ImPACT concussion severity ( P = .171).

Multivariate Logistic Regression Analysis a

a Values are expressed as odds ratio (95% CI). Bolded P values indicate statistically significant difference compared with reference (Ref) variable ( P < .05).

b Multivariate logistic regression analysis was not conducted for concussion severity between goalkeepers and non-goalkeepers.

We found no significant differences among player age groups in terms of incidence of suspected concussions and severity index when controlling for sex, position, learning disability diagnosis, ADHD diagnosis, chronic headaches, chronic migraines, dyslexia diagnosis, autism diagnosis, previous concussion history, and altitude. Using age 15 to 16 years as the reference, we noted a significant difference compared with players aged ≥17 years in terms of ImPACT concussions (OR, 2.157 [95% CI, 1.159-4.017]; P = .0153) suspected concussion severity (OR, 0.192 [95% CI, 0.05-0.671]; P = .0097), and ImPACT concussion severity (OR, 0.177 [95% CI, 0.038-0.833]; P = .0285). The lack of ImPACT concussions among the players aged 12 to 14 years limited the ability to draw conclusions about concussion severity for that age group versus players aged 15 to 16 years, but it did not affect the comparison of players aged 15 to 16 years versus ≥17 years.

We found no significant differences among player positions in terms of incidence of suspected concussions and severity index when controlling for sex, age, learning disability diagnosis, ADHD diagnosis, chronic headaches, chronic migraines, dyslexia diagnosis, autism diagnosis, previous concussion history, and altitude. Using goalkeepers as the reference, we noted a significant difference compared with forwards in terms of ImPACT concussions (OR, 0.312 [95% CI, 0.103-0.941]; P = .039). No significant differences were found between goalkeepers and non-goalkeepers with regard to suspected or ImPACT concussions.

The major findings of our study were that female players (vs male players) and players aged ≥17 years (vs those aged 15-16 years) experienced a higher incidence of ImPACT concussions (mean, 0.07 ± 0.35 vs 0.04 ± 0.21 concussions per person-year for male players [ P = .05] and 0.07 ± 0.35 vs 0.04 ± 0.27 concussions per person-year for players aged 15-16 years [ P = .040]). Multivariate analysis confirmed only the age-related increase (OR, 2.157 [95% CI, 1.159-4.017]; P = .0153). Additionally, goalkeepers had a greater incidence of ImPACT concussions compared with forwards, which was confirmed via multivariate analysis (OR, 0.312 [95% CI, 0.103-0.941], P = .0387). Players in the 15- to 16-year age group showed increased suspected concussion severity compared with the ≥17-year age group (coefficient = –1.293; P = .001), although this was not confirmed via multivariate analysis. However, we found that sex and player position did not significantly affect initial concussion severity, and further study is required to understand whether there is an association.

Although soccer is a leading cause of sports-related concussion, few studies on concussion in soccer have been performed. 2 , 6 , 7 , 10 , 16 , 17 , 22 , 26 , 30 The studies that have been done primarily have been focused on sex and age differences. Few studies 2 , 10 , 26 have looked at differences among positions, and those that did looked primarily at concussion incidence and not concussion severity. In our analysis of sex-based differences, our univariate results aligned with those of previous research performed on concussion incidence among soccer players based on sex. 6 , 17 , 28 However, our multivariate results did not confirm these results. Literature 8 , 9 , 12 , 25 on concussion and sports in general has concluded that women experience a higher incidence of concussion. One possible reason that female players experience a higher incidence of concussion is because they are more inclined to report a head impact and their subsequent symptoms. 15 This may lead to a higher incidence of suspected concussions and, in turn, ImPACT concussions. A variety of hypotheses are available indicating why female soccer players experience a higher incidence of concussion. First, male players have been reported to have stronger and bigger neck and torso muscles, which may enable them to better endure collisions, resulting in a lower incidence of concussion. 10 , 23 Migraines serve as another potential predictor for higher incidence of concussion, and studies have shown that female players experience a higher incidence of this condition. 8 Our severity finding coincides with other literature that has found no significant sex-based differences on postinjury ImPACT Test performance. 11 , 30

The effect of age on concussion risk is also highly relevant, as soccer governing bodies across the country continue to explore how rules and playstyle modifications can best be implemented at different ages to reduce the risk of concussion. 28 One benefit of our study is that we looked at specific age groups, whereas other work on concussions in soccer has compared high school versus collegiate athletes. 6 , 8 , 11 , 12 , 17 Our dataset included players aged 12 to 22 years, enabling us to examine athletes of different levels, including middle school, high school, and college. We found that older soccer players experienced a greater concussion incidence, which has been noted in previous literature. 9 , 12 , 17 , 25 A study 29 on players aged 10 to 19 years found that players in the 15- to 19-year age group sustained a greater incidence of concussion than did the other age groups. In addition, research 9 , 19 , 24 has indicated that high school athletes perform worse after concussion and have longer recovery times compared with collegiate athletes. Similarly, using the severity index, we found an increase in concussion severity for the 15- to 16-year age group as compared with the other age groups.

One explanation that supports why older soccer players experience a higher incidence of concussion is that older athletes play soccer at a more competitive level, leading to more frequent head impacts. 12 Also, older players are more likely to have sustained a concussion in their earlier years of playing, which puts them at a greater risk of a subsequent concussion. 22 Our finding that players in the 15- to 16-year age group experienced more severe concussions than did those in the ≥17-year age group could be partially explained by smaller and weaker neck and torso muscles in younger players. 10 , 23 This increases the chance of a more harmful collision, resulting in a more severe concussion. Despite this, the difference in competition level between the 15- to 16- and 12- to 14-year age groups likely outweighs the biological differences between the 2. Specifically, players in the 15- to 16-year age group play high school soccer, which is much more physical compared with younger levels. As a result, the potential for a more severe concussion is much greater.

Our analysis based on position showed no association between initial concussion severity and player position. However, our finding that goalkeepers experienced a higher incidence of concussion than did forwards is consistent with some of the previous literature. 9 , 10 Although goalkeepers do not engage in heading the ball, a heavily studied concussion mechanism in soccer, this does not mean they have a lower incidence of concussion. 1 In fact, research has shown that head-to-ball impact is not a leading cause of concussions in soccer. However, goalkeepers, as the last line of defense, are the most inclined to be involved in high-acceleration, unintentional collisions (with players as well as with the ground or the goalpost). 16 Considering these results, we can conclude that goalkeepers are at an increased risk of sustaining a concussion while playing soccer compared with forwards. Despite this, the athlete’s position does not have to be considered when trying to limit the severity of concussions. Boden et al 2 found that defenders were at the greatest risk of sustaining a concussion, and Weber et al 26 found forwards to be at the greatest risk. It is important to note, however, that some of these studies had smaller sample sizes and/or only looked at collegiate athletes. Boden et al had 29 participants with concussions, Delaney et al 10 studied 201 participants with 62.7% concussed during the season, Lamond et al 16 reported on 23 participants with concussions, and Weber et al had a total of 381 participants with 34 concussed participants. The contrast between our results and those of some of the other literature on the topic suggests that the incidence of concussion among soccer players based on position may warrant further research.

Our study had limitations. There was no way to definitively determine whether the reported concussions were from playing soccer. Although all athletes listed soccer as their primary sport and were likely injured while playing soccer, some athletes may have participated in multiple sports and possibly may have been injured in another sport. Another limitation was that the data collection did not include body mass index and test environment, which can be potential moderators of neurocognition. After looking at the dates of concussion of the players in the study, we found that the majority of concussions were sustained during the high school soccer season. Some players in the study may have played on a club soccer team year-round, which would be a plausible explanation for why participants in the study sustained concussions outside of their high school seasons.

Despite the large sample size associated with the overall study, the prevalence of severe ImPACT concussion among the 12- to 14-year age group was low. This was likely due to a lower level of dangerous physical contact in the age group, but it does limit our ability to draw conclusions about differences in that age group. Additionally, ImPACT may only be available at schools with increased resources, which may have biased the study population. Sole use of ImPACT without other tests may have decreased sensitivity for detection of clinical concussion. 20 ImPACT protocol dictates that initial postinjury testing should be done within 48 hours of injury, but many athletes did not report the date of initial injury. Last, unaccounted variation in level of participation, athlete skill level, and other environmental factors may have affected results.

Female soccer players experienced a higher incidence of concussion than did male players, and goalkeepers experienced a greater incidence of ImPACT concussions than did forwards. Players of both sexes and all positions in the 15- to 16-year age group showed increased initial concussion severity compared with those in the ≥17-year age group, despite a lower comparative incidence of ImPACT concussions. Further study is needed to understand whether sex and player position affect concussion severity. It is important to analyze the root causes of concussions that occur among soccer players because that knowledge, in addition to the differences in severity and incidence among different demographic groups explored in this study, will help parents, physicians, coaches, and athletic trainers identify who is at risk and how athletes receive concussions—critical information in concussion prevention.

Final revision submitted June 29, 2021; accepted August 4, 2021.

The authors have declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Ethical approval for this study was obtained from Mount Sinai School of Medicine (IF2563222, 87 IF2315880).

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Pitt Leads Breakthrough in Concussion Research

The Pitt Panthers could soon be one of many to benefit from their own university's concussion research.

• Author: Stephen Thompson

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PITTSBURGH -- The same university that birthed the polio vaccine has engineered another medical breakthrough. And as the University of Pittsburgh pioneers new developments in the world of concussion detection and treatment, it could have lasting effects on the Pitt Panthers' teams.

According to a report from Abby Mackey of the Pittsburgh Post Gazette, Dr. David Okonkwo, a professor of neurological surgery at Pitt, has created an FDA approved a lad-quality device of his team's creation that is capable of detecting concussions quickly. It could be used in hospitals, in the field and, potentially, on the sidelines of football games and other sporting events.

A bedside blood concussion test, with Pitt research, finds FDA approval https://t.co/eVZJMeUSz9 — Pittsburgh Post-Gazette (@PittsburghPG) April 18, 2024

The device, called the i-STAT Alinity, is the next evolution of a device Okonkwo's team had already researched. The i-STAT TBI was similar to the Alinity in that it took bood samples and tested them to diagnose concussion rapidly, but it was limited in scope and use because it took blood serum samples, which had to be processed via centrifuge in a lab. The Alinity takes whole blood samples and doesn't require a lab or centrifuge to process, according to Okonkwo.

According to Mackey's reporting, the Alinity is able to rule out concussions with 96.5% accuracy when patients are assessed within 24 hours of injury and could tell if a CT scan to rule out bleeding in the brain is necessary.

Abbott, the company that manufactures the device, predicts that it will be available for use in emergency rooms and urgent care centers this summer and could begin being used by the United States military at the same time. It hasb't been adopted by health care systems or insurers just yet but Abbott expects it will eventually be treated like any other routine blood diagnostic test.

That said, the use on the sidelines at football games and other sporting events will not come as soon for the Alinity.

“The nature of the studies performed to gain FDA clearance for these tests were done in patients brought to level one trauma centers,” Dr. Okonkwo said. “We have every reason to believe there is significant overlap with the injuries to athletes who sustain a concussion, but we need to do studies specifically in that patient population to confirm that use.”

The device is currently approved for use on patients 18 and older but it will have to gain approval from sports leagues, players' unions and individual teams before it finds its way into the spotlight for big time college or professional sports.

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How oj simpson became the star witness in a pivotal 1970 trial over helmet safety – and set back cte research for decades .

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In March 1970, OJ Simpson served as a witness in a landmark court case brought by the family of a paralyzed football player against a major helmet maker. His adroit performance on the stand, experts say, helped the NFL shrug off the dangers of CTE for decades.

Two years after winning the Heisman Trophy at USC and a year after becoming the first-round draft pick for the Buffalo Bills, Simpson was tapped by the legal defense team of Rawlings Sporting Goods.

The equipment maker had been slapped with a $3.6 million lawsuit – the first of its kind to reach a jury – by the family of Ernie Pelton. The former running back at Sacramento, Calif.’s Rio Linda High School had been paralyzed from the neck down after a helmet-to-helmet hit in 1967.

Simpson – already a local hero at the time around his hometown of San Francisco before becoming a national celebrity – charmed a star-struck jury as he defended the plastic helmets produced by Rawlings, according to the Sacramento Bee.

“I believe in this helmet,” Simpson, who wore a Rawlings helmet as a running back for the Bills,  testified in Sacramento County Superior Court , according to the newspaper.

“I know every time I get on the field, there’s a chance I get hurt.”

Asked on the stand to read the warning label inside the Rawlings helmet – which said players should “avoid all purposeful contact” – Simpson quipped, “I try, but haven’t succeeded.”

Simpson also testified that he used a Rawlings helmet during his high school playing days in San Francisco — like the same helmet Pelton was wearing when he suffered the life-altering injury.

Lawyers for Rawlings argued during the trial “that the game of football is at stake,” with one of the attorneys asking Simpson if he was aware of the sport’s inherent risks.

“A person would be pretty ignorant if he didn’t know,” Simpson replied. “I know every time I get on the field, there’s a chance you can get hurt like the Pelton boy.”

After Simpson’s testimony, the jury sent a note requesting to have their photos taken with the gridiron star,  according to an account of the trial by political journalist Melody Gutierrez .

The Sacramento Union newspaper ran a photo on March 11, 1970, with the caption: “Simpson signs autographs for jurors.”

Weeks later, the jury ruled in favor of Rawlings. Simpson – who died April 10 at age 76 and was cremated after his family  refused an analysis of his brain for concussion damage  – helped pave the way for a verdict that helped shield the NFL for generations to come from addressing the dangers of chronic traumatic encephalopathy, or CTE, industry experts said.

“If Pelton won, it would have been devastating to football,” said Robert Erb, the CEO of helmet maker Schutt Sports from 2008-2020. “The NFL, NCAA and high school football had to be relieved.”

Helmet liability expert Kimberly Archie added:  “It made attorneys afraid to take on other cases.” 

There were a few victories against helmet makers in the ensuing years. In 1974, MacGregor was ordered to pay $3.5 million by a Rhode Island jury for selling a defective helmet, but a judge later reduced that penalty by 40% saying the youth player was partially responsible.

A year later, the family of an Indiana 13-year-old won $5.8 million from Rawlings because there was no warning label on the helmet.

But for the most part, helmet makers and the NFL were able to skirt any significant financial damage for decades because of the ruling in the Pelton case.

“It reinforced the ‘assumption of the risk is on the player legal defense’,” Erb told The Post.

“If you want proof of how important that verdict was you can look at the number of patents filed in the years after for new helmet designs. There was little development.”

The NFL continued to ignore that many of its players were exposed to brain damage from violent helmet-to-helmet contact well into the 21st century, growing into the nation’s most popular sport largely on the bone-jarring hits highlighted in its own NFL Films videos. 

Rawlings finally stopped making helmets in 2015 after losing several suits filed by the families of youth football players who suffered head injuries.

It was around that time that the NFL stopped turning a blind eye to CTE, which can only be diagnosed after someone dies. Symptoms include erratic impulsive behavior from bruising to the brain caused by repetitive head trauma. 

The tide began to turn as alleged evidence emerged that the NFL had been hiding studies that showed the impacts of repeated head injuries, undermining the argument that players knew the risks of football.

NFL stars like the Chicago Bears’ Dave Duerson and San Diego Chargers’ Junior Seau were found to suffer from CTE after their brains were analyzed following their tragic suicides.

Former New England Patriots Tight End Aaron Hernandez, who in 2015 was found guilty of first-degree murder,  hanged himself in prison in 2017. An analysis  of his brain  found  that he had CTE.

In 2018,  Simpson told The Buffalo News he was “concerned”  he might have  developed CTE  during his career, admitting that he suffered a pair of concussions.

“I do recognize that it probably affects you in short-term memory more than long-term,” he said. “I know with me, I have days I can’t find words. . . . That gets a little scary.”

Dr. Bennet Omalu, the doctor who connected CTE with football and was portrayed by actor Will Smith in the 2016 movie “Concussion,”  said he would bet his medical license that Simpson suffered  from CTE.

The league has since done laboratory testing to evaluate which helmets best reduce head impact injuries. These tests recreate the unique impacts players at each position tend to experience on the field, an NFL spokesman says, adding that the league now approves safer helmets.

It’s still not enough, Erb said, pointing to the increase in concussions suffered by today’s players. He pinned some of that blame on the league increasing the length of the season from 14 games in the early 1970s to the current 18-game format.

“The NFL is just as much of a meat grind as it was back in the 1970s,” Erb said. “The NFL is spending more money on advertising about safety and throwing dinners for neurologists than on fixing the problem.”

Overall, the NFL since the 1970s has had 20 games, the league said. The format in 1978 went to 4 preseason games and 16 regular season games. In 2022, the format switched to 3 preseason games and 17 regular season games. The overall 20 game season has remained consistent, an NFL spokesman said.

“In 2023, concussion numbers largely remained steady compared to the previous season,” the NFL spokesman said, and significantly lower than the 2015 to 2017 baseline.

Meanwhile, the NFL’s change in attitude toward helmet safety came way too late for Ernie Pelton and his family, who was left to care for the quadriplegic for the next five decades with little financial help. He died in 2007 after spending his life in bed attached to medical equipment. 

The family blames Simpson for siding with Rawlings.

“We would have won if OJ didn’t testify,” Pelton’s sister Malinda Lacusky told The Post. “Ernie didn’t get a good case because such a famous man testified against him.”

Simpson’s decision to take the secrets of his brain to the grave added salt to the wound, the industry experts said.

“I think the NFL is relieved. The last thing they needed was to learn that OJ had CTE. They don’t need or want that,” Erb said.

Archie agreed.

“As one of the most well-known NFL Hall of Famers, O.J.’s brain being donated to science could have made an enormous impact in awareness,” she said. “That is part of OJ’s legacy. He was a part of football fooling the public about safety.”

Simpson’s lawyer did not return calls.

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