On the Question of Antonio Brown and CTE

By Dr. Chris Nowinski, Concussion Legacy Foundation co-founder and CEO

For years, the erratic behavior of NFL All-Pro wide receiver Antonio Brown has been a cause for concern as many have watched and worried for his mental health. In Sunday’s Tampa Bay Buccaneers game, Brown had another episode of abnormal public behavior. After a sideline dispute with Bucs coaches, he took off his shoulder pads and jersey, threw his shirt and gloves into the stands, performed jumping jacks for the crowd, and walked off the field. He is no longer a member of the team.

A lot of people are worried and speculating that Antonio Brown is exhibiting signs of CTE. As a CTE researcher and CEO of the Concussion Legacy Foundation, I’d like to use this opportunity to educate the public on what we do know about the disease and how it progresses.

Like you, I wonder if Antonio Brown’s behavior is caused by CTE. We can’t know for sure today, because CTE can only be definitively diagnosed after death. However, the recent diagnosis of CTE in two former NFL contemporaries of Brown’s, Vincent Jackson and Phillip Adams, can provide insights into the two separate but related questions we’re trying to answer: does Antonio Brown have CTE and is it causing his destructive behaviors?

Question 1: Does Antonio Brown have CTE?

Vincent Jackson’s story gives insight into whether Brown may have CTE. Jackson was a 3-time Pro Bowl wide receiver for the Tampa Bay Buccaneers and the San Diego Chargers from 2005-2016. He was found dead in a hotel on Feb 15, 2021 at the age of 38.

Jackson’s brain was studied by Dr. Ann McKee at the VA-Boston University-Concussion Legacy Foundation Brain Bank, where she discovered he had stage 2 CTE.

Previous work from the VA-BU-CLF Brain Bank has shown that the odds of developing CTE are not statistically related to how many concussions you have, but instead correlates with how many years of football you play. A football player’s odds of developing CTE go up by as much as 30% per year. Vincent Jackson started playing football at age 12 and played 11 years in the NFL.

Antonio Brown has now played 12 years in the NFL and according to ESPN started playing tackle football before high school, meaning he likely played more years than Vincent Jackson. On top of the years he’s played, Brown ranks 21st all-time in receptions, which means, among wide receivers and tight ends, he’s also among the most tackled NFL players of all-time.

In 2019, when Brown was asked if he had CTE, he told ESPN:

“If I had CTE I wouldn’t be able to have this beautiful gym, I wouldn’t be able to be creative. I wouldn’t be able to communicate. I’m perfectly fine.”

Those comments illustrate a fundamental misunderstanding of CTE. Later stage CTE (stage 3 and 4) is associated with dementia, but early-stage CTE (stage 1 and 2) is more associated with what is called neurobehavioral dysregulation, which includes violent, impulsive, or explosive behavior, inappropriate behavior, aggression, rage, “short fuse,” and lack of behavioral control.

Brown went on to say, “I didn’t take that many big hits. I had like one big hit in 10 years. Anybody who plays this game, they’re going to get hit hard. He didn’t hit me that hard. You know, I got up and walked off the field.”

Brown’s words are eerily similar to a statement Jackson made two years before his death when asked about CTE: “I was fortunate, trust me. I never took many major hits.”

The big hit Brown is referring to is the one below from Vontaze Burfict in 2016, which caused loss of consciousness and therefore by definition caused a significant traumatic brain injury (TBI).

Independent of whether Brown has CTE, TBI is also associated with acute onset of similar neurobehavioral symptoms. It’s plausible that the TBI could account for his abnormal behaviors since then.

However, the more concerning reality for all of us former football players is that it’s not the big hits, but the accumulation of all the smaller hits we never thought about, that cause CTE. 20% of former football players diagnosed with CTE have never had a formally diagnosed concussion.

Finally, it’s important to note that CTE is extremely prevalent among NFL players. A 2017 study from the VA-BU-CLF Brain Bank revealed that 1 in 10 of the NFL players who died between 2008-2015 were diagnosed with CTE, and 99% of the 111 players studied had CTE. Accounting for the fact that families that noticed severe symptoms are more likely to donate, it’s likely a minimum of 10% of NFL players have CTE, and it could be many, many times higher.

Question 2: If Antonio Brown has CTE, is it causing his destructive behavior?

CTE was largely ignored by the medical community for the 80 years after Dr. Harrison Martland published Punch Drunk in the Journal of the American Medical Association in 1928. Therefore, we are still learning what symptoms are directly caused by CTE.

The evidence strongly suggests that stage 4 CTE causes dementia in most cases, but it’s not so clear which symptoms are regularly caused by early-stage CTE. But it would not be surprising if we eventually prove that the earliest stages of CTE are associated with an increased risk of psychiatric symptoms. A study on the earliest stages of Alzheimer’s disease found that pathology in the locus coeruleus (early-stage CTE also impacts the locus coeruleus) is associated with increased depression, anxiety, and sleep disorders.

What we have shown about CTE is that stages are most associated with age. That means everyone starts at stage 1, with microscopic CTE lesions in their brain, while they are getting exposed to repetitive head impacts, usually as a teenager or in their 20s (CTE has been confirmed in people as young as 17).

CTE then spreads to adjacent tissue and new parts of the brain, progressing at different speeds in different people due to differences in exposure, genetics, and more. Most football players who die in their 30s are diagnosed with stage 2 CTE. Aaron Hernandez was the youngest football player diagnosed with the more advanced stage 3 disease when he died at 27.

Earlier this year, former NFL player Phillip Adams shot and killed 6 people, including two young children. Adams then turned the gun on himself and died at the age of 32. His brain was studied by Dr. Ann McKee at the BU CTE Center, and she discovered he had stage 2 CTE with abnormally severe damage to the frontal lobe of the brain.

Investigators said they never found a motive for the murders. Toxicology revealed Adams was not under the influence of any substances at the time of the murders. Police reported finding numerous notebooks with “cryptic writing with different designs and emblems,” and his sister said his behavior had changed dramatically over the last two years.

“His mental health degraded fast and terribly bad,’’ Lauren Adams told USA TODAY. “There was unusual behavior. I’m not going to get into all that (symptoms). We definitely did notice signs of mental illness that was extremely concerning, that was not like we had ever seen. He wasn’t a monster. He was struggling with his mental health.”

When asked if the killings could be explained by CTE, Dr. Ann McKee said, “Severe frontal lobe pathology might have contributed to Adams’ behavioral abnormalities, in addition to physical, psychiatric and psychosocial factors. Theoretically, the combination of poor impulse control, paranoia, poor decision-making, emotional volatility, rage and violent tendencies caused by frontal lobe damage could converge to lower an individual’s threshold for homicidal acts — yet such behaviors are usually multifactorial.”

Phillip Adams and Antonio Brown were born 10 days apart and were both NFL rookies in 2010. But Adams had retired by 2015. Brown is still playing.

Answering the Question:

Based on everything we know about CTE today, it is possible that Antonio Brown has CTE, and that CTE is causing his behaviors. But you already knew that.

The bigger question is what do we do with this information?

First, we need to invest more in preventing and treating CTE.

Football is less obviously dangerous than it was in years past, with a number of rule changes introduced designed to reduce concussion risk and concussion protocols. But that doesn’t mean we’ll see a reduction in future cases of CTE. Most of the reforms made focus solely on concussion, not reducing CTE. And what’s not said enough is that all the changes may be completely offset by the fact that football players at every level are bigger, stronger, faster, and therefore creating higher magnitude impacts and more CTE. Even Junior Seau’s CTE now looks mild compared to more advanced cases we are now seeing in college football players who died in their 20’s.

We don’t invest nearly enough in learning how to meaningfully treat CTE, which not only impacts athletes but also military Veterans and victims of abuse.

In 2015, the NFL pulled $14 million from research designed to learn how to diagnose CTE. To wipe that headline off the front page, the NFL quickly announced a $100 million donation to brain research, but only put a few million of that towards CTE research, instead putting $60 million toward safer helmets, which isn’t going to make much of a difference in CTE but creates hope and headlines. (Did you hear about new position-specific helmets?) When you think about helmets and CTE, think about trying to prevent automobile deaths by only investing in better bumpers. It’s such a small piece of the puzzle.

Second, I think Tom Brady had it right when he said, “I think everyone should be very compassionate and empathetic towards some very difficult things that are happening.”

Antonio Brown’s mental health has been unraveling on a public stage for many years. CTE could be the cause of everything. Or it could not.

But that doesn’t change the fact that a staggering number of former football players, contact sport athletes, military Veterans, and others are suffering from CTE, and we don’t have answers.

At the Concussion Legacy Foundation, we’re trying to get those answers before it’s too late.

What we do know right now – and what we want to make very clear to Brown and anyone else like him who may be reading this: help is available. CTE is not a death sentence. Just because you have years of exposure to repetitive head trauma does not mean you are destined to exhibit certain behaviors. There are ways to take control of your brain health and we have a team at CLF ready to teach you how. Our HelpLine staff is filled with caring individuals who are here to assist patients and families suffering with CTE symptoms. We can connect you to treatment in your area and providers who understand what you’re going through. You are not alone.

If you’d like to join us in the fight against CTE, there are several ways to get involved. If you’d like to donate your time, sign up to participate in research. If you’d like to learn about the easiest way to prevent CTE, learn about Flag Football Under 14. If you’d like to make a donation, click here. If you’d like to stay educated on CTE, sign up for our newsletter.

New Brain Bank Study Sheds Light on My Past

By Chris Nowinski, PhD

CLF co-founder and CEO

My quest to understand and treat the long-term effects of concussions and repetitive head impacts (RHIs) is not just an academic pursuit – it’s personal. Our team studies individuals with a history of RHIs, a history that I share. Each study helps me better understand my brain health, and what I can expect in the future. Sometimes the news is positive.

Our latest study is not. It serves as a stark reminder that we urgently need effective treatments for concussions and CTE, and we need your help to do it.

Last week I coauthored a VA-Boston University-CLF Brain Bank study led by Dr. Mike Alosco and Dr. Ann McKee that reveals magnetic resonance imaging (MRI) can tell us more than we previously knew about the brain health of an athlete who has been exposed to repetitive head impacts (RHIs). The study, Association Between Antemortem FLAIR White Matter Hyperintensities and Neuropathology in Brain Donors Exposed to Repetitive Head Impacts, was published in Neurology, the medical journal of the American Academy of Neurology and covered well in The Guardian.

I have about 16 years of exposure to RHIs. Eight years of American football, about five years of soccer with heading, and professional wrestling for three years. I retired from professional wrestling in 2003 due to post-concussion syndrome.

Our research team collected and analyzed MRIs from 75 of our brain donors taken during life and compared them to their post-mortem findings. 67 of the subjects played American football and 70% had CTE.

We discovered the volume of a well-known MRI abnormality, white matter hyperintensities, was related to years of American football play and correlated with neuropathological changes like white matter rarefaction, arteriolosclerosis, p-tau accumulation, and CTE stage, as well as reported cognitive symptoms in symptomatic brain donors exposed to repetitive head impacts. Simply put: the longer the football career, the more white matter hyperintensities found, and the higher likelihood for symptoms.

As a symptomatic future brain donor exposed to repetitive head impacts, this news is not welcome. When I wrote Head Games: Football’s Concussion Crisis in 2006, I shared a story from my first visit to see now-CLF medical director Dr. Robert Cantu in 2003. He ordered an MRI, and on my way home from the scan, the technician called me and told me I needed to come back for a follow-up MRI the next morning. She wouldn’t tell me why. My imagination ran wild.

While in the MRI the next morning, I could see Dr. Cantu in the next room reading the images live. Long story short, I had so many white matter hyperintensities that Dr. Cantu had to rule out multiple sclerosis. I didn’t have MS. Instead, he told me my brain lesions likely represented dead brain tissue from prior head impacts and concussions. The full passage is below.

At that time, the findings didn’t bother me. What was done was done.

Now, 18 years later, I know what was done is not done. Those lesions may be an indicator of worse things to come.

For those of us who used our heads as battering rams, the clock is ticking. If you’re still on the sideline in the fight against CTE and other consequences of head impacts, it’s time to get in the game. If you’d like to get more involved, email me at [email protected].

EXCERPT BELOW FROM HEAD GAMES (2006)

Dr. Cantu decided to perform an MRI to see if there was any physical evidence of brain damage. I told him that I’d already had one, and it was negative. “While it’s a long shot, sometimes the evidence can take a while to appear, and sometimes you just have to know what to look for,” he said. I left the doctor’s office with more answers, but even more questions.

A few days later, I drove back to the hospital for my second MRI in two months. The MRI process is always impersonal; you don’t know the nurses and technicians, and they don’t know anything about you, save for the part of your insides that a doctor wants to see. This encounter was no different. I slipped into the tube with nary a word spoken. Some people find being trapped in that tiny tube with the loud noises and vibrations of the machine claustrophobic. I’ve had so many MRIs over the years that I usually fall asleep.

This particular morning, the technician interrupted my nap. My new habit of acting out my dreams was causing me to squirm, ruining the MRI images. When I left, I felt anxious about the test results. Yet, since I was confident they wouldn’t find anything wrong, I figured the only harm done was having wasted the morning.

On my way home from the hospital, I got a phone call from a number I didn’t recognize. It was the MRI technician. With a strange tension in her voice, she urged me to return the next morning for another test.

Hesitating, I asked, “Why, did something not work?”

“We’d like to take some more pictures” was all I could get her to say.

I couldn’t tell if she was hiding some huge discovery that they would only tell me in person, or if she honestly didn’t know why they wanted to see me again. Either way, that’s a phone call you don’t want to get. I got more worried when I found out that this busy MRI center (I’d had to wait over a week for my first appointment) had cleared an early morning appointment for me the next day.

From the moment I ended the call, I desperately tried to figure out what diagnosis could possibly require such an urgent second test. Scenarios ran through my mind like flash cards. The stack of cards was short, due to my lack of knowledge of the brain and my lack of imagination. I could only think of two legitimate reasons why I had to go back. Either they had made a mistake, and nothing was wrong (this is what I was hoping for) or they had found a brain tumor (this terrified me). What else could be so urgent that I had to go back to the hospital the next day, but not urgent enough that I didn’t have to go that very second? I figured that a tumor would explain why my symptoms weren’t going away.

I had to stop torturing myself, so I distracted myself by watching a movie, and then tried to go to bed. I figured I’d have plenty of time to make myself crazy on the 45-minute drive to the hospital the next morning. Despite my best efforts, and the usual sleeping pills, I didn’t get much rest that night.

When I arrived the next morning, everything seemed eerily normal. The same nurses and technicians were there. No one was acting weird—as far as I could tell. They slid me into the tube again. There was a mirror over my head set at a 45-degree angle so I could see out past my feet—probably there for the claustrophobics. I had a good view of the technician’s room, where they watch the live pictures on computer screens. In my experience, there are usually only one or two people in the technician’s room. I did a quick head count. One, two, three, four . . .Uh, oh, I thought. That’s too many people.

In addition to the two technicians, I saw Dr. Cantu and another man wearing a lab coat. I assumed he was the doctor scrutinizing the pictures on the screens. No one had told me that all those people would be there. I don’t think I was supposed to know they were there. It was just my luck that two workmen were installing new blinds over the windows that day, so the doctors were in full view. I felt a wave of nausea and started to sweat. I wanted out of the tube.

After twenty more minutes of agony, the test was over. The doctors had left, and the technicians weren’t very talkative. I was told to go up to Dr. Cantu’s office on the eighth floor. That hadn’t been on the agenda either. Not good. When I arrived, there were four people in the waiting room, but I wasn’t even given a chance to sit down. I was whisked right in to see the doc.

By this time, I think I’d stopped breathing. Dr. Cantu must have noticed, because he gave me an overly reassuring smile.

“Don’t worry, you’re fine.”

A wave of relief swept over my body, followed by a wave of confusion. “What did you think was wrong?”

“Well, Chris, you have a few small areas in and on the surface of your brain that show up as white spots on the MRI. Multiple white spots can be early evidence of multiple sclerosis. We had to rule that out, and we did.”

“How?” I asked.

“If you had MS, you’d have a lot more of the spots.”

He seemed satisfied. I was not. “Okay, then what are these spots?”

“Well, the answer is that we don’t know . . . I would venture to guess they’re most likely the residual evidence of tissue damage caused by impacts—concussions. But they look like they’ve been there for a while, so they’re probably not from your latest ones.”

“Does that confirm that I’ve had concussions that I didn’t know about?”

“More than likely,” he answered.

I sat back in my chair and let it all soak in. Sweet. I have dead chunks of brain from all those shots I took over the years. I didn’t know that was even possible. By the end of the week, I would receive a physical copy of the MRI report, and would discover that “a few areas” meant five, and “small” meant as big as 4mm x 3mm on some slides. I didn’t know what was considered big, but I decided that that was all the dead brain tissue I was comfortable having.

Concussions and Suicide: What We Know

By Dr. Robert Cantu
CLF co-founder and medical director

Suicide is one of the leading public health problems impacting individuals, families and communities. According to the CDC, suicide was the tenth leading cause of death overall in 2019 and the second leading cause of death among individuals between the ages of 10 and 34. The brain injury community is disproportionately affected by suicide, and the Concussion Legacy Foundation is here to help you help those you love.

Studies show individuals who have experienced a concussion are at a higher risk of suicide. A 2018 study published in the Journal of the American Medical Association found those who were diagnosed with concussion or mild TBI were twice as likely to die by suicide compared to those who had not been diagnosed with a concussion or mild TBI. A 2021 study published in the Journal of Neurotrauma revealed young people under age 26 are especially vulnerable to novel psychiatric disorders after concussion. The study found the share of subjects reporting suicidal ideation jumped from 1.4 percent at the time of their concussion to 4.7 percent 180 days later.

It is important for parents, coaches, teachers, friends, and teammates of concussed individuals to be prepared to support a loved one’s mental health after a concussion. Symptoms of concussion can include anxiety, depression, and panic attacks. People suffering from long-term effects of concussion, especially children and adolescents, can also experience feelings of isolation when they are forced to be away from their athletic teams, activities, and school during their recovery.

If you are the parent, coach, teacher, friend, or teammate of someone who may have suffered a concussion, you can help keep them safe by making sure they are removed from activities that could further injure their brain. Your opportunity to help doesn’t stop there, though. You can also play a crucial role in their recovery by making sure they feel supported, cared for, and heard – even if they are away from you or your group. A check-in text can go a long way to help someone feel less isolated.

While risk of suicide is elevated after a concussion, it is imperative to know it is not common. Research has shown over 99 percent of people who have a concussion do not experience a suicide-related event. Although concussion increases the relative risk of suicide, the absolute statistical risk remains very low.

So – does concussion cause suicide? The short answer is no. While there are risk factors and warning signs for suicide, a suicide cannot be attributed to one single cause. According to the American Foundation for Suicide Prevention, suicide most often occurs when stressors exceed current coping abilities of someone suffering from a mental health condition. The symptoms of concussion can contribute to suicidal ideations.

Suicide is preventable. It is not inevitable for anyone. Those who are suicidal should seek the help of mental health professionals. Those who are worried about a friend or a loved one who may be suicidal should know there are resources available to support them.

Below is a list of life-saving resources for someone who may be suicidal:

For those who are worried about a friend or loved one or for those who want to do their part in preventing suicide, check out these important resources:

We have lost far too many people to suicide. Tragically, many of our Legacy Donors whose brains have been studied at the VA-BU-CLF Brain Bank were victims of suicide. Research is ongoing to investigate the links between concussion, CTE, PTSD, and suicide to help us find treatments for the effects of brain trauma and prevent future tragedies.

For now, let’s do our part to prevent suicide. Memorize the crisis lines and warning signs and learn the best practices for helping someone through a mental health crisis. Above all, know help is out there and you are not alone.

A youth football video made you sick. But is some outrage misplaced?

By Chris Nowinski, Ph.D.
Concussion Legacy Foundation co-founder & CEO

You know the video, even if you haven’t seen this version yet. A semi-circle of young boys with enormous-looking football helmets watch two of their teammates line up across from one another. A whistle blows, and the two players – who perhaps weigh 100 pounds combined, if you count the helmets – sprint straight at each other and collide.

We hear the CRACK of the helmets and watch the horrifying whiplash of the younger, lighter, or less prepared boy as he falls in a heap to the ground.

Cue the Twitter outrage from fans, coaches, TV personalities, and even the CEO of USA Football.

“This drill needs to be banned!”

“The weaker player is clearly outmatched – that’s on the coach.”

“This is against everything we stand for.”

If you are part of the social media pile-on decrying bull-in-the-ring drills and ill-informed coaches, I’d like you to consider that your anger may be misplaced.

Is there really a safe way for a 40-pound child wearing a gigantic 4-pound helmet to run at another child and tackle him to the ground? I’d argue there is not. While the coaching is horrendous, it isn’t the biggest problem with this viral video, and it won’t be the problem when we get angry about a similar video next year. The existence of youth tackle football is the bigger problem. Because even “well-coached” tackle football with “evenly matched” players is inappropriate and dangerous for young children while their brains are developing.

When you start children in tackle football while their age is still a single digit, you are essentially priming them to develop the neurodegenerative disease Chronic Traumatic Encephalopathy (CTE). The perception that CTE is a problem exclusively for NFL players is a myth. The research tells us you don’t need to play at the highest levels of football to develop CTE; you just need to play long enough.

A 2019 study by researchers at Boston University and the US Department of Veterans Affairs published in the Annals of Neurology concluded the risk and severity of developing CTE is not correlated to the number of concussions one receives, but is instead correlated with the number of years spent playing tackle football. Their odds of developing CTE appear to go up 20 to 30% per season they play. That means that a high school football player who starts tackle football at age 5, instead of age 14, may have an incredible 10 times the risk of developing CTE.

Symptoms of CTE include explosiveness, impulsivity, rage, violent outbursts, having a “short fuse” or emotional lability, depression, paranoia, cognitive impairment, memory loss, and dementia.

This alarming data means that if you start your child too young, and they succeed, their brain is in peril. Signing a child up to play a season of tackle football may not put them at a noticeable risk of CTE. But a coach’s job is to teach the child how to play well, and to enjoy the game. If that coach is successful, the player may go on to play in high school, and by then they will already have a significant risk of developing CTE. If they start at 5 and go on to play in college, the risk would be even higher. So if you have a promising football player in your care, the last thing you want them to do is play youth tackle football. The brain can only take so much trauma. If you wait until high school, they may learn the lessons of the game and avoid CTE.

If you are still an advocate for youth tackle football because you believe children can be taught to tackle safely, I’d argue you are using the wrong measure of safety. They may survive each individual tackle, but eventually all those tackles can catch up to them. Many of the hundreds of former football players with CTE in our brain bank were the best tacklers on their team or were known for good form. But even the most skilled tacklers are often surprised when a ball-carrier changes direction at the last moment.

The science says young children also do not have the brain development to consistently tackle safely, no matter how much you train them. If you really believe five, six or seven-year-old children can control their bodies well enough to tackle and be tackled with perfect form each time, are you open to letting them try other activities we restrict to adults? Go ahead and teach your five-year-old to drive. Then tell me you are surprised when they drive you into a tree. Sure, you can teach them the rules of the road, and perhaps even how to safely drive around an empty parking lot, but do you trust them to execute it all safely on the highway going 65 in the rain?

A better choice for youth players is flag football. A U.S. Centers for Disease Control (CDC) study published in February, 2021 in Sports Health reported youth tackle football athletes ages 6 to 14 sustained 15 times more head impacts than flag football athletes during a practice or game and sustained 23 times more high-magnitude (hard) head impacts. The study also measured the total number of head impacts experienced during the season. Researchers found youth tackle football athletes experienced a median of 378 head impacts per athlete during the season compared to only eight head impacts for flag football athletes.

Remove bull-in-the-ring from youth tackle football, and you’re left with a sport that may produce fewer viral videos, but one that is still exceptionally dangerous for young children to play. No child should receive 378 head impacts in a season.

My advice to parents is simple: if you wouldn’t hit your child in the head 50 times a week in the fall, don’t let other people do it to them either. The brain develops in profound ways during its journey to adulthood. Every season of hits can change the brain and therefore change the child.

Just ask the families of John Gaal Jr., Evan Hansen, or Kenny Keys whether CTE can affect football players who never made it to the pros. John, Evan and Kenny are three of the more than 1,000 former athletes and military Veterans whose brains have been donated to the VA-BU-CLF Brain Bank after death for research on CTE and other forms of brain trauma.

As a former All-Ivy football player-turned neuroscientist who has watched CTE destroy hundreds of families, I have dedicated my life to preventing CTE. We launched Flag Football Under 14 to encourage parents to delay enrolling their children in tackle football until age 14. We estimate that if all football players started playing tackle at age 14, we would eliminate more than 50% of future CTE cases.

You can learn more about CTE and the dangers of youth tackle football using the links below. What you won’t find is a page on how to coach youth tackle football responsibly. There is simply no safe way to do it. So next time a viral video pops up of a big youth football hit, I hope you’ll help us ask the question that really needs to be asked: why are we letting young children hit each other in the head hundreds of times each year?

CDC report validates CLF’s impact on sports concussions

By Chris Nowinski, Ph.D.
Concussion Legacy Foundation co-founder & CEO

When I wrote Head Games: Football’s Concussion Crisis with the help of CLF co-founder and medical director Dr. Robert Cantu in 2006, my goal was not only to educate about the dangers of concussions in football, but also to detail football reforms to prevent concussions. Last week the CDC issued a new study that conclusively shows this campaign of education and reform, led and executed by the Concussion Legacy Foundation, has been successful beyond our wildest imaginations.

On July 9, the U.S. Centers for Disease Control and Prevention (CDC) published Trends in Emergency Department Visits for Contact Sports–Related Traumatic Brain Injuries Among Children — United States, 2001–2018 in their prestigious Morbidity and Mortality Weekly Report. It shows the rate of football-related TBI Emergency Department (ED) visits declined by 39% from 2013 to 2018, after increasing more than 200% from 2001 to 2013. This is the best evidence yet that the Concussion Legacy Foundation has made a profound and long-term positive impact on the health of youth and high school football players.

The data, illustrated in Figure 2 below, reveals that the 200% increase in football-related ED visits from 2001-2013 primarily occurred after 2007. That was the year we began our public-facing education campaign to increase awareness of the risks of concussion, as chronicled in this 2007 HBO Real Sports episode and documentaries like PBS Frontline’s League of Denial and Head Games: The Global Concussion Crisis. We blew the whistle, and concussions that were once ignored now resulted in immediate medical care and better outcomes for football players. The study also showed benefits in increased ED visits for concussions in other sports like basketball and soccer.

After the five-year surge in football-related ED visits reflecting increased awareness, we would have expected to see a plateau in the absence of effective reforms focused on concussion prevention.

Instead, this new data reveals football-related ED visits declined by a remarkable 39% since 2013. The CDC credits the 24% drop in participation in youth tackle football since 2010 as one component of that change. The participation decline coincides with Dr. Cantu speaking out against youth tackle football in his 2012 book Concussions & Our Kids and summarized in this 2012 New York Times Op-ed. His bold proposition inspired CLF’s ongoing Flag Football Under 14 campaign.

The CDC also credits the “implementation of contact and tackling restrictions” as a likely contributing factor to the decline in football-related ED visits. In 2006’s Head Games I wrote, “One simple but radical idea that would reduce concussions is to limit the number of full-contact practices.”

We were not able to implement that reform at the highest level until the NFL Players Association recruited us to the new Mackey-White Health & Safety Committee in 2010. At the first meeting, attended by members, staff, and NFL players, each expert was asked to speak for five minutes on which concussion reform they thought was most important for players.

Dr. Cantu and I knew the evidence showed upwards of 60% of head impacts occur in practice, and no other reform would be as effective at reducing concussions, so we both advocated for contact practice restrictions. We were the only experts to mention it, so I was doubtful it would become policy. Fortunately, the NFL players in the room immediately saw the logic and codified significant contact restrictions in practice into their 2011 Collective Bargaining Agreement. Soon after, as a member of the new Ivy League Concussion Committee, I asked coaches to lead football to a better future by becoming the first college conference to have formal contact limits in the sport. Although these early adopters had already limited hitting in practice below the threshold, they agreed to make it policy. By 2013, the idea began to trickle down to high school and youth coaches, and ED visits for concussions began to decline.

We are not the only individuals or organization that deserves credit for this extraordinary public health victory. We thank the many scientists who published the data that inspired and validated these reforms, Dr. Ann McKee and the Boston University and VA researchers who have taught us about CTE, the families of our brain donors who have made so much of this research possible, members of the football and medical communities who advocated for change, and the many football players and families who have gone public with their struggles.

We are proud to have led the concussion education movement and inspired the reforms to football responsible for the initial increase, and now promising decline, in ED visits for concussions. This movement has undeniably made football players safer. We thank the CDC for compiling and interpreting this important data. Most importantly, Dr. Cantu, the CLF team, and I could not have done this without your support – and for that, we thank you.

But the fight isn’t over. The CDC concludes, “These findings highlight the continued need to expand efforts to prevent football-related TBIs among children and call attention to the need to identify effective prevention strategies for other contact sports.”

We are committed to concussion and CTE prevention through CLF’s Flag Football Under 14 and Safer Soccer programs, which aim to eliminate repetitive head impacts for children before age 14.

We are committed to supporting the generations of former athletes affected by concussions through programs like the CLF HelpLine and Patient & Family Services.

We are committed to accelerating the search for effective treatments for concussions and CTE through the VA-BU-CLF Brain Bank and Brain Donation & Clinical Research Registry.

We are committed to continuing to make a difference. If you’d like CLF to continue to succeed, please make a donation today.