Nicholas D. Wright, M.D.: Ethical issue facing high school football

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WILLIAMSTOWN — It's time, on ethical grounds, for the Massachusetts Interscholastic Athletic Association (MIAA) to launch a co-educational touch-football league for the state's high schools.

As a retired epidemiologist, I know that doctors and parents alike are increasingly aware of and concerned about the long-term brain damage — and learning problems — which can be caused by head-impact concussions. Public and charitable educational institutions that sponsor contact sports cannot let themselves become the equivalent of the tobacco companies of the 21st-century by failing to respond to the alarming possibility that they are damaging young minds.

As currently applied, "Return to play after concussion protocols" protect the game and the institution, but not the players. In a recent appeal to the Mount Greylock Regional School District board, I recited the evidence for my suggestion, and how parents are reacting.

It is now clear that chronic traumatic encephalopathy (CTE), first identified post-mortem by Dr.Bennet Omalu in the autopsied brain of the late 50-year-old Pittsburgh Steeler Mike Webster, is a reliable marker for contact-sports exposure. To date, however, CTE cannot be visualized in living athletes and it is not known when the process begins or how it may progress over time. That said, age at first exposure (less than 12) to tackle football is associated with greater later-life cognitive impairment.

CTE starts early

Based on a study at the University of Michigan, we know just how common head impact is in high school football. Over a 14-week season comprising 190 practice sessions and 50 games, 102,000 impacts were recorded. The average player sustained 652 impacts. For linemen the number was 868. Finally, we know that CTE is not exclusively found in former NFL players. At autopsy, CTE has been found in young men who did not play football after high school.

Since high school rates of concussion in baseball, basketball and wrestling are 10, 25 and 30 percent respectively of the concussion rates in football, a case could be made to suspend football, and concentrate on the safer sports.

Improvements in the quality of the athletic health literature since the 1990s have improved our understanding of the connection between sub-concussive and concussive blows and long-term brain damage. We have learned as well that at least 50 percent of the problem centers in men's football. If this epidemic of brain damage appeared in the short term, as with boxing's "dementia pugilistica," we would have acted already to control the damage.

Despite the extensive "cultural" support for football, parents of up to 800,000 of an estimated 3 million Pop Warner League participants have withdrawn their sons. It can be expected that high school participation rates will soon be affected.

Unfortunately, it could take decades-long observational studies to definitely establish the causal connection between concussive and sub-concussive blows to the head and subsequent premature dementia, depression, and other adverse neuro-cognitive outcomes. So in effect, we are where the tobacco and cancer story was in the 1950s, when tobacco companies were still claiming that any relationship to multiple cancers was a "mere statistical association," not a causal one.

I recognize that beyond the three prevalent three D's (deny, defer, and delay), some limited measures have been taken to address this epidemic of brain damage. Contact in practice has been reduced, safer tackling techniques taught, and risky play on game day sometimes penalized.

Additionally, "Return to play after concussion" protocols have been established and are increasingly applied as secondary prevention. But these are of very limited usefulness because most concussions are not recognized or reported, and neither the clinical screening nor the neurocognitive tests are sensitive enough to detect accurately when a player is fit to play, much less "recovered." A new finding among concussed athletes that the risk of serious lower extremity musculo-skeletal injury is increased 2 1/2 times over matched, non-concussed athletes suggests the persistence of subtle neuro-cognitive deficits not detectable by standard screening.

Weak counter-claims

That we know so little of the natural history of CTE does not keep enthusiasts from claiming that these protocols have averted prospective brain damage. Such claims have no firm basis in the epidemiological or clinical evidence. Beyond perhaps preventing the thankfully rare complication of "second-impact syndrome" it is clear that the "return to play after concussion" protocols protect the game and the sponsoring institution more than the players.

Largely missing from the literature are comprehensive studies of "returning to learn after concussion" despite plentiful anecdotes about chronic headache, visual disturbance, weeks in dark rooms, and academic "adjustments." One has the sickening feeling that, as weak as our concern is for the players as athletes, it is even less for them as scholars. In an academic institution professing the development of young minds, is that not a serious ethical matter?

If for cultural reasons it is too difficult for the MIAA to discourage tackle football, it should agree to meet its ethical obligation by setting up a parallel touch-football league. As tackle football begins its death spiral in high schools, students, including women, would have the opportunity to enjoy a much safer and less costly game, and one more consistent with the traditional "sound mind, sound body" rationale for sport.

Nicholas H.Wright, M.D. is a retired epidemiologist.


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