High School Football: Time out. Steven Miles MD Department of Medicine Center for Bioethics University of Minnesota

Objectives: Participants will Understand the relevance of the organization of pre-college football to reforms to reduce brain trauma. Be able to apply current science on the effects of pre-college football as it relates brain trauma. Be able to design a better informed consent for school football. Be able to evaluate proposals for game modification as it relates brain trauma.

INSERT TITLE TEXT HERE Demographics

4.1 Million Students Play League Football

INSERT TITLE TEXT HERE The Science of Repetitive Brain Trauma NOTE: For clarity, I am focusing on studies of high school students and will not include studies of NFL or college players. I also do not discuss acute catastrophic brain injuries (e.g. hemorrhages) or neck, spine, orthopedic or visceral injuries.

Definition: Collision Sport Athletes purposely and frequently hit or collide with each other or inanimate objects with great force. American football, rugby, boxing, ice hockey, full contact martial arts.

J Athl Train. 2007;42: 495–503. Note: Concussions are undercounted. Subconcussive Repetitive Brain Trauma not counted.

Concussion A subset of Traumatic Brain Injury. Low velocity injury that causes brain ‘shaking’ resulting in clinical symptoms. May be caused by a direct blow to the head or by an "impulsive" force transmitted to the head. Typically, rapid-onset, short-lived impairment resolving spontaneously or evolving over minutes to hours to longer. May involve loss of consciousness. May cause neuropathology but is largely a functional disturbance rather than structural injury. Traumatic Brain Injury A blow or jolt to the head, or a penetrating head injury that disrupts normal brain function. Can result from the head violently hitting an object, or an object pierces the skull to enter brain tissue. Symptoms can be mild to severe. Mild traumatic brain injury may result in a brief change in mental state or consciousness, while severe cases may result in extended periods of unconsciousness, coma or death. – 4th International Conference on Concussion in Sport held in Zurich, Switzerland in 2012

Chronic Traumatic Encephalopathy Always follows repeated brain trauma. A neurodegenerative disease. Wide deposition of hyperphosphorylated tau (P-tau). Some correlation with APO ε3. Neurology 2013;81; Young onset Initial behavioral/ mood disturbance Minimal motor cognitive disturbance Young onset Initial behavioral/ mood disturbance Minimal motor cognitive disturbance Older onset Cognitive and motor impairments Older onset Cognitive and motor impairments

Players received 200 to 1,850 hits to the head / season. Impact forces: 20 to 100+ Gs! Max was 280Gs. [Headkick in soccer is ~20 Gs.] 3x as many players showed brain changes as experienced concussion. BasePreseasSeas 1 Post J Biomech 2012;30;45: Two year study of high school football players. Helmet Accelerometers. fMRI. Develop Neuropsych 2015;40(2):92-7. "The level of change in the fMRI signal is significantly correlated to the number and distribution of hits that a player takes. Cognitive performance didn't change, but brain activity changes, showing that certain areas are no longer being recruited to perform a task.”

Age of first exposure to tackle football and later-life corpus callosum (CC) microstructure using MRI diffusion tensor imaging 40 retired NFL players, age 40-65, matched by age were divided into two groups (before / after age 12) of first exposure (AFE) to tackle football. Former NFL players in the AFE <12 group had significantly lower Fractional Anisotropy and higher radial diffusivity (indicating impaired white matter connectivity) in the corpus callosum than those in AFE ≥12 group. – J Neurotrauma 2015;32: – Develop Neuropsych 2015;40:92-7. – J Neurotrauma 2014;31:

Repetitive Head Impact (RHI) and Long Term Cognition RHI: cumulative concussive and subconcussive trauma damages the brain. The Cumulative Head Impact Index CHII quantifies RHI. It combines self-reported athletic history (i.e., # of seasons, position(s), etc,) and impact data from helmet accelerometers. A threshold dose-response relationship was found between CHII and – later-life cognitive impairment (p<0.0019), – self-reported executive dysfunction (p<0.0003), – depression (p<0.0009), – apathy (p<0.0040), – behavioral dysregulation (p<.0001) J Neurotrauma. March doi: /neu former high school and collegiate football players that completed objective cognitive & self-reported behavioral/mood tests as part of a larger longitudinal study.

Athletes with recent concussions performed had worse attention and concentration. Symptom-free athletes with two or more concussions performed like youth with a recent concussion. Cumulative GPAs were lower for athletes with two or more previous concussion groups and for those with recent concussions. – Neurosurg 2015;57: boarding high school athletes. – J Neurotrauma 2014;31: Number of Concussions

CTE in young people "I unequivocally think there's a link between playing football and CTE,... [in five years] we've found it in 45 out of 55 college players and 6 out of 26 high school players.” “It cannot be rare.” Its not about limiting concussions; its about limiting head injuries. – Dr. Ann McKee, professor of neurology and pathology at Boston University. Testimony. House Energy Committee Hearing 3/14/16. votes/event/broad-review-concussions-initial-roundtable

Joseph Chernach played football grades 5-12 and stopped : His mood and academic performance steadily deteriorated in college. 2012: Suicide by hanging at age Pop Warner paid “less than $2 million” to family. “Very severe changes in the brainstem, with numerous tau neuro- fibrillary tangles in the locus coeruleus... These findings indicate Stage II, possibly Stage III CTE.”

INSERT TITLE TEXT HERE Game Modification?

Preventing Repetitive Head Injury in Youth Football There is no evidence-based validation of: Reformed Return to Play Policies (Either design or enforcement). Improved helmet design Changes in tackling rules (except for some rules on kick-off returns) The Heads-Up program of USA Football or CDC. Kids reporting symptoms of concussion – J Law Med. & Ethics 2014;42:323-9 – N Engl J Med 2016; 374: – Amer J Sports Med 2014;42:

The AAP’s child-centered mission is “to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults.” 1957: “football has no place” for children under : Competitive Athletics for Children of Elementary School Age. “Unless a school or community can provide exemplary supervision medical and educational it should not undertake a program of competitive sports, especially collision sports, at the pre-adolescent level.”

2010: “Young athletes pose a unique challenge, because their brains are still developing and may be more susceptible to the effects of a concussion.” – Sport-Related Concussion in Children and Adolescents : “Removing tackling from football altogether would likely lead to a decrease in the incidence of overall injuries, severe injuries, catastrophic injuries, and concussions.... [however, removing] tackling from football would lead to a fundamental change in the way the game is played. Participants in football must decide whether the potential health risks of sustaining these injuries are outweighed by the recreational benefits associated with proper tackling.” - Tackling in Youth Football

Lead author has a non-disclosed conflict of interest. Dr. Mark E. Halstead is a team physician for the St. Louis Rams, St. Louis Blues, Washington University Athletic Teams, and Lafayette High School. Entirely focused on concussion. No discussion of repetitive subconcussive trauma. Passing reference to the effects of concussion on academic performance. No evidence-based template for informed consent. Optimistically speculative (e.g. proposing neck strengthening might decrease the catastrophic neck injuries or cautions that that raising the age at which tackling is allowed might increase injuries.)

INSERT TITLE TEXT HERE Informed Consent

Standard Consent Doesn’t disclose risks. Misleading contextualization (e.g., “There is a degree of risk in all daily activities.”) Doesn’t rebut ungrounded hope of 26% of parents, especially those with economic and educational disadvantages, that their child will turn school participation into a professional athletic career. Mainly liability waivers. – Amer J Bioeth 2016;16:6-10. Parents and students should be aware of prelim- inary evidence that suggests repeat concussions, and even hits that do not cause a symptomatic concussion, may lead to abnormal brain changes which can only be seen on autopsy (known as Chronic Traumatic Encephalopathy (CTE)). There have been case reports suggesting the development of Parkinson’s-like symptoms, Amyotrophic Lateral Sclerosis (ALS), severe traumatic brain injury, depression and long term memory issues that may be related to concussion history. Further research on this topic is needed before any conclusions can be drawn. Florida High School Athletic Association files/orig_uploads/gov/sportsmed/ minutes/ pdf

Honest Informed Consent Repetitive brain injuries are common in youth football although the long term effects on a particular player cannot be predicted. A symptomatic concussion increases the risk of future concussions, future brain injuries and the chance of a catastrophic injury resulting in paralysis or death. Repetitive head trauma from tackle football is likely to adversely affect attention, memory, and school performance for weeks and possibly for the long term. Coaches cannot detect most brain injuries. Brain damaging injuries do not require the symptoms of a concussion. Some young people get progressing and untreatable brain diseases from participating in collision sports like football. This can result in poor college, occupational and social performance and depression. School football is not a likely path to a college scholarship or a professional sports career. 1 /16 high school football players will play on a college team. 1 / 1,200 high school football players will play on a pro team. The average pro career is 3.3 years. Pro players have much higher rates of depression, thinking problems, and physical disabilities than the general public. General medical insurance is the student’s responsibility. The school does not provide or pay for long-term rehabilitation or vocational retraining, long term care or adaptive aids like crutches or wheelchairs. The school does not provide disability insurance for lost income. Amer J Bioeth 2016;16:6-10. Amer J Sports Med 2015;43:

INSERT TITLE TEXT HERE Social Trends

Prior to School football declining.5% per year. nStatics.aspx/ Non-school football declining 4% per year. er/pop-warner-youth-footballparticipation-drops-nfl- concussion-crisis-seen-causal-factor The trend (different method): tackle football up % in 2015 as flag football up 9-10%. game/participation-tackle-and-flag-football- increases-2015 School tackle practices are decreased. (Ivy League has given up tackle practices.) Some schools and cities are ending tackle programs. Age for tackle being raised. “Stronger” rules for taking players out. “Stronger” head trauma training for coaches. More medical expertise at game side (often not practices). There are increasing numbers of lawsuits against teams, leagues, schools, and state football associations.

An Immodest Proposal NB: Mr. Swift proposed to consume children for the ‘public good.’ I propose that we stop doing so.

Close Down School Football Programs It would decrease incentives to play for the school or to reap academic rewards (excused time, leniency in academic performance). It would refocus school physical education programming and resources to fitness sports of life- time participation (e.g., working out, jogging, tennis, bicycling, swimming) rather than spectator or team sports. – It would not end the ‘right’ to play football although it would reduce public expenditures for football.

Game Over Steven Miles MD Slides available at my faculty website