Are Football Players Suffering Concussion-Like Damage in the Absence of a Concussion?

Ken Mautner, MDWith the NFL playoffs just around the corner – and our Atlanta Falcons certain to be in them – most of us have been watching a lot of football lately. Like many football fans, I watch simply to enjoy the games, but lately I’ve been watching with a new question in the back of my mind: Are any of the players receiving what we call “sub-concussive hits” that might over time, contribute, to concussion-like brain problems?

The question was prompted by a recent study published in the Journal of Neurotrauma. The study looked at youth football players who had never had a concussion, had never complained of the symptoms typically associated with a concussion, yet showed changes in brain activity and cognitive ability that are normally associated with people who have suffered one or more concussions.

We have a lot of experience treating concussions at Emory Sports Medicine. My focus is to get athletes, parents and coaches to know and recognize the symptoms of a concussion, and to seek out prompt concussion treatment when they have those symptoms. What should be done when athletes may not present any of the traditional symptoms? Or what about athletes who have not, in fact, had a concussion but who are experiencing similar problems associated with concussions?

We’re learning about this phenomenon because our tests for concussions have become far more sensitive and sophisticated in the last few years. In the study mentioned above, “hit monitors” – telemetry units – were installed in the studied athletes’ football helmets to measure the g-forces they took with every hit in practice and games throughout the season. Computerized neuropsychological testing (CNT) was administered, both pre-season and post-season, to assess changes in cognitive functional ability. And functional magnetic resonance imaging (fMRI) was used to look for telltale increases of activity in certain areas of the brain that are typical in those who have suffered concussions.

The surprising finding was that some athletes never sustained a hit strong enough, as measured by the hit monitors, to cause a concussion, and yet the fMRI and CNT results showed evidence of the characteristic increases in brain activity and decreases in cognitive ability normally associated with a concussion. This result was most common among offensive linemen, who may take 40-50 sub-concussive hits in a single, ordinary practice. Over the course of a season, this massive accumulation of lower g-force hits seems to have caused the same effects we’d usually expect only from more powerful, concussion-causing hits.

Long-term consequences are what concern me most here. It’s possible that brain activity and cognitive ability return to normal after the season is over and the youth athletes have had some time to recover. It’s also possible that some of these effects are enduring. Just as with those who suffer multiple concussions, it may be that this accumulation of sub-concussive hits will, years later, result in higher incidences of depression and cognitive impairment. We don’t know yet if this is the case, but the study has raised the possibility.

My own son plays Pee Wee Football, and I appreciate the self-discipline, toughness, and teamwork he learns from it. But like any parent, I have to weigh that value against the potential for negative long-term consequences. Everything in life is a trade-off of risks and benefits, but this recent finding adds a new variable to the decision.

So, what’s to be done? Well, first of all, we have to keep pressing forward with efforts to prevent, identify, and treat concussions. Concussions remain a serious problem in football and other contact sports, particularly among adolescent athletes, whose brains are especially vulnerable. I’m part of a group of health care providers and state action planners who are working in partnership with the NFL to pass legislation in Georgia to better prevent concussions and provide better treatment for those who do suffer concussions.

Some of the same measures being considered to prevent concussions, such as better helmet technology, may also prevent the damages of sub-concussive hits. The NFL is even considering more drastic changes, such as eliminating the traditional three-point stance, thereby requiring linemen to start with their hands off the ground. This change would greatly reduce the number and force of helmet-to-helmet hits. Should the NFL make this change, it will most likely be adopted by college, club, high school, and lower grade football leagues.

Ultimately, what we need is more research. The concussion testing we perform at Emory Sports Medicine has become far more sophisticated in recent years, and it will continue to become even more sensitive. Now that we’re aware of the effects of sub-concussive hits, I’m confident we’re just a few years away from being able to identify those athletes who may be at risk. I look forward to the day when I can again watch the gridiron drama without worrying that the players are fighting their way toward that Super Bowl ring at the cost of the long-term health of their brain functions.

For more information, check out the study, Functionally-Detected Cognitive Impairment in High School Football Players Without Clinically-Diagnosed Concussion. If you have questions, please don’t hesitate to leave them in the comments below.

About Dr. Ken Mautner, MD:

Dr. Mautner is an Assistant Professor in Emory’s Department of Physical Medicine and Rehabilitation and the Department of Orthopedic Surgery. Dr. Mautner currently serves as head team physician for Agnes Scott College and St. Pius High School and a team physician for Emory University Athletics. He is also a consulting physician for Georgia Tech Athletics, Neuro Tour, the Atlanta Ballet, and several local high schools.

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