By: Kushal Chatterjee
February 11, 2024 - Super Bowl Sunday. An audience of nearly 125 million watched Patrick Mahomes and the Kansas City Chiefs topple Brock Purdy’s San Francisco 49ers in overtime on a late February evening. Super Bowl LVIII shattered all previous TV viewership records, suggesting that the exhilarating game of football continues to captivate viewers and increase its influence worldwide. Whether people were tuned in to see the prowess of the 49ers and Chiefs, support Chiefs superfan Taylor Swift’s team, or analyze the halftime show and advertisements, it is clear that football’s biggest event has massive leverage worldwide.
Unfortunately, what is often forgotten in the thrills and disappointments of NFL football is a topic that demands our utmost attention and critical examination: the neuropsychological consequences of participating in football. Increased neurological research and attention has suggested that the game takes a ghastly toll on the brain health of its athletes. This article dives into the neurological repercussions associated with playing football, analyzing the scope and complexity of this issue, whilst offering potential solutions that may allow the players to safely and healthily play the sport that we so cherish. Join me on this journey of exploration, where we aim to find the intricate balance between fervent competition and spectator captivation while preserving the long-term health of our athletes and their brains.
Football’s Catastrophic Effects on the Brain
From the early 2000s, neurological research has analyzed the brains of former football players. Unfortunately, a common theme arrived at the forefront of these analyses: signs of severe neurodegeneration and repeated traumatic blows to the head. These observations were critically linked to a neurological illness known as chronic traumatic encephalopathy, or CTE, which is commonly found in individuals with chronic head trauma, a classic byproduct of playing football. CTE has been found to have a variety of catastrophic effects that affect all domains of an athlete’s brain, psychology, and life. CTE leads to depression, impulsive behavior, rages, memory loss, and eventually disorders like the early onset of dementia. Incidents of severe neurodegeneration have often ended in uncontrollable substance abuse and deaths related to drug overdose. It seems quite proven that the repeated head-to-head impact that is associated with football is extremely detrimental to athletes not only in the short run with repeated concussions and injuries, but also downstream beyond their retirement from the sport.
In order to further understand why repeated head traumas from football can result in neurodegenerative disease, it is important to understand the physiological changes happening in the brain due to football. One of the underlying proteins behind the neurodegeneration seen in CTE is the tau protein. Tau is a microtubule associated protein (MAP) that functions in stabilizing microtubules that transport nutrients within brain cells. Repeated brain trauma alters the tau proteins in the brain chemically, often causing them to pair with other tau threads and tangle up. These dysfunctional tau proteins, having a misfolded tertiary structure, are no longer able to sustain their physiological function, which leads to microtubule death and loss of neural activity, a mechanism similar to what is observed in elderly Alzheimer’s patients. However, the effects of football seem to manifest in the brains of its athletes much sooner than the classic Alzheimer’s diagnosis that is associated with the geriatric population. While not immediate, the signs of CTE affect athletes within 5-10 years of the end of their football careers, which means that many of these players start to experience neurological dysfunction from a relatively early age.
Brain researchers found that elevated levels of misfolded tau protein could be detected in living brains through a technique called positron emission tomography (PET). In late 2013, UCLA researchers scanned the brains of living NFL retirees using FDDNP, a radioactive marker that is able to cross the blood-brain barrier and bind to tau in the brain, creating a visible fluorescence in the brain scans. The research group found shocking similarities in these living NFL retiree brains to the cognitive dysfunction seen in brains of patients with Alzheimer’s disease, while also noting that tau accumulation in the brains of NFL retirees also occurred in the deeper recesses of the brain, not just in the cortex. The patterns seen in the scans of these living NFL brains intricately matched the trends from empirical brain autopsies done on individuals with CTE posthumously. This concerning result definitively suggested that the head trauma associated with playing NFL football has similar neurodegenerative outcomes as diseases like CTE and Alzheimer’s. The penetration of tau into the deep recesses of the brain allows it to associate with the hippocampus, which explains the memory impairment that athletes experience, and can also bind to regions of the amygdala, which can lead to uncontrollable rage and an inability to control one’s emotions, some of the classic psychiatric symptoms of football-induced brain trauma.
Quantifying our Laboratory Observations - Are the Current NFL Brain Injury Statistics on a Positive or Negative Trajectory?
Looking at the two graphs of NFL concussions per game week and total NFL concussions in the full season, the red trendlines for both graphs seem to suggest that the frequency of concussions in the NFL has steadily decreased in the past decade. While this is extremely promising news, suggesting that preventative measures such as increased safety considerations and further medical research has reaped quantitative benefits for the brain health of football athletes, it is important to note that the rate of decrease in concussions over the decade has at most been approximately 25%. This means that while the frequency of concussions have decreased by about a quarter or less, concussions still remain a persistent problem in modern football to this day because the rate of decrease has only been moderately gradual. Regardless, this result still seems to provide a glimmer of hope to healthcare professionals and the league that what has been done so far is working; however, it also emphasizes that more needs to be done. Therefore, the rest of this article will explore a specific recent case study of an NFL player’s journey battling three head injuries in less than three months, and then evaluate two modern research solutions that aim to further inhibit brain injury and neurological degeneration in NFL athletes, allowing us to understand what more can be done to bridge the gap between spectator enjoyment, competition, and preservation of athlete health as the primary long-term goal.
Case Study: Tua Tagovailoa’s 2022 Season
The 2022 NFL season for Tua Tagovailoa, the Miami Dolphins starting quarterback, was marked with horrifically worrisome head injuries. In Week 3 of the season against the Bills, Tua suffered a concussion at the end of the first half, as the back of his head was slammed to the turf by a linebacker. Tua demonstrated ataxia, a lack of muscle control, which caused the Dolphins staff to remove him from the game for a few plays to close the half. Regardless, after the halftime break, Tua was medically cleared to return to the game.
Fast forward to a few days later - the Dolphins Week 4 game was on a short week, playing Thursday Night Football against the Bengals. Tua, being listed as questionable in the practices leading up to Thursday, was somehow cleared through concussion protocol and allowed to start on Thursday, a mere 4 days after his first concussion. In the first half of this game, Tua suffered another gruesome and disturbing head injury, causing him to remain on the ground for minutes whilst experiencing a fencing response. A fencing response is a neurological state where an individual’s arms and fingers move into an unnatural position following a traumatic brain injury. Tua’s second injury prompted outrage from NFL fans, health professionals, and neuroscientists. It seemed that the NFL concussion protocol needed substantial rewiring as it was seemingly prioritizing the ratings from the games over the long-term health of their athletes. Later that season after making his return from two concussions, Tua suffered a third concussion on a Christmas day game which ended his 2022 season prematurely. All in all, Tua suffered 3 concussions in less than 3 months, demonstrating serious neurological impairment due to the repeated traumatic hits, whilst still being cleared through protocols to play eerily rapidly.
As we explored earlier, it is clear the repeated head trauma endured by NFL athletes is extremely detrimental for their long-term neuropsychological health. However, another important inquiry remains, which is to explore the relationship between head injury status and on-field importance. Through an analysis of Tua’s 2022 NFL stats before his head injuries and after his head injuries, we are offered a glimpse of how the brain health of NFL athletes affects their performances on the field, which may suggest to teams that playing their star players despite injury may not be the appropriate choice.
Looking at the graphs above, we see a clear discrepancy between the on-field performance of Tua Tagovailoa before and after his concussion suffered against the Green Bay Packers with two minutes left in the first half. Therefore, Tua played ~28 minutes before suffering a concussion, and continued to play the full second half of ~30 minutes after his concussion, so the statistics are appropriately scaled for similar time intervals. The discrepancy between his first half and second half stats is dire; before his concussion, Tua was throwing a perfect game with 229 first half passing yards, 1 touchdown, and no interceptions. After he suffered his concussion and was regardless permitted to play in the second half with his injury, Tua’s stats dramatically regressed, as he threw for a total of 81 passing yards and 3 interceptions in the second half. The Dolphins went on to lose the game, scoring zero points in the second half whilst being up by a touchdown at the halftime break.
This on-field statistical analysis of a live concussion case study demonstrates that not only is it seriously not safe for players to continue playing after suffering a head injury, but it also shows that a head injury has direct consequences on performance and game outcomes. Therefore, the NFL should universally learn from this example and amend the concussion protocol in an effort to protect the long-term health and welfare of its players, rather than prioritizing TV ratings and blindly playing star players despite health complications because it is clear that the coercion of injured players is negatively correlated with performance.
Solution #1: Radical Helmet Designs
Stanford researchers have theorized an innovative football helmet design that is estimated, based on computerized models, to reduce concussions by 75%. This carbon-fiber helmet has insertions of liquid shock absorbers throughout the columns of the helmet. The liquid, typically water or oil, is able to absorb a significant deal of the massive kinetic energy of a football hit and thereby limit the force being transmitted to the athlete’s skull and brain. Moreover, guardian caps, which are the padded soft shells worn above football helmets, have decreased concussions by 52% during NFL training camps and practices. It still does not seem that guardian caps will be implemented into the gameday equipment for enhanced player safety due to other limitations. The NFL continues to perform research into position-specific helmets that are equipped to prevent head injuries based on the common trends of each position group; for example, most quarterback concussions occur when the back of the quarterback’s head is slammed against the ground while getting sacked. Therefore, quarterback helmets with additional protection at the back of the helmet would greatly enhance concussion-related outcomes for the position.
Overall, shock-absorbing helmets that act in a similar mechanism to airbags in automobiles will greatly disperse and soften the force from a collision. The evolving world of science and engineering may help in helmet design with enhanced cushioning and trauma prevention; however, there is no perfect helmet model that can completely prevent the issue of brain injuries and concussions. The sport of football is simply too violent in its very nature.
Solution #2: Cannabis to the Rescue
Another promising avenue for prevention of neurodegeneration associated with football is the use of anti-inflammatory cannabinoids. Two important cannabinoids have attracted neuroresearchers’ attention: tetrahydrocannabinol (THC) and cannabidiol (CBD). Both of these active compounds in cannabis have been found to demonstrate neuroprotective abilities through their function in reducing brain inflammation and the accumulation of harmful proteins in brain cells, such as the tau protein. Both THC and CBD seem to be able to prevent cell death, as well as assist in the repair process for currently damaged neurons and mitigate further injury. Therefore, while seemingly paradoxical and certainly not approved in mainstream for football players yet, chronic cannabis use does display a modulatory role in neural injury by suppressing the neuroinflammatory response and enhancing oculomotor resilience.
The NFL has currently allocated $1 million of funding into research regarding the efficacy and safety of cannabis products with high levels of THC and CBD for concussion neuroprotection. The hope is that cannabis products, if proven safe and effective for whatever the optimal daily dose is found to be, will replace opioid prescriptions that NFL athletes currently use for pain management; cannabinoid-based therapeutics may soon be taken by athletes from a young age in order to mitigate the effects of neural damage.
Putting an End to Gridiron Dementia
In conclusion, neurological research has demonstrated that the repeated head-to-head collisions and brain trauma associated with NFL football has led to neurodegenerative dysfunction in the brains of its athletes. Neurological diseases such as CTE have altered the lives of football players well after their tenure playing the sport, suggesting that the consequences of playing football last for a lifetime, beyond the glory of the sport.
With this being said, the trend across the last decade seems overwhelmingly positive. Through the implementation of additional neurological safety procedures by the NFL, rule changes, and a focus on researching how the sport of football can be made safer for its athletes, concussion and other brain injury rates have steadily decreased over the past decade. However, there is still much scope for improvement as the effects of brain injury are dire and long-lasting for the athletes who are affected.
Two potential solutions were discussed extensively in this article - the implementation of modern engineering advances to redesign the football helmet to include liquid shock absorbers, as well as the use of cannabinoids as a means of thwarting neural inflammation and mitigating future brain injury. By fostering a culture of awareness and scientific research becoming the priority factor that guides proactive measures, the NFL can play its part in ensuring a safer and more sustainable future for its athletes, thereby cementing a positive legacy for the sport and its heroes. By combining measures of equipment advancements, rigid rule enforcement, immediate and accurate medical evaluations, and embracing their immersion into the constantly evolving and path breaking world of neurological research, the NFL and its associations can evolve football into a safer sport that preserves its physical competitiveness and popularity whilst prioritizing the health and emotional well-being of its competitors.