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The end-of-August announcement that the National Football League will pay $765 million to settle a lawsuit involving thousands of its former players over problems related to head trauma is just one sign of the growing concern that the sport’s collisions pose a serious risk to long-term player health. But little is known about how a season of head hits affects the largest group of football athletes: the nearly 4.5 million youth and high school student players.

A study by researchers in North Carolina and Virginia is addressing this gap with the most comprehensive look at the relationship between impacts and injuries in players from ages 6 to 18. By combining biomechanics, brain imaging, and neurological testing, the team could develop tools to identify when a player has been hit hard enough, or repeatedly enough, to risk a concussion or other brain injury. In July, the researchers reported a new way to calculate head injury risk over a season based on data from accelerometer-equipped helmets. The researchers also used brain scans to examine those same players to search for links between measured head impacts and changes in brain tissue and function. Those results are still being analyzed.

Around one million Americans play high school football, and more than three times that many play in youth leagues. While athletic trainers and physicians stand on the sidelines of professional and college games, high school and youth players often depend on coaches and parents to watch for problems. “The younger that you get in football, the more people you have playing and the less attention paid to having medical personnel present at the games to assess function in players,” says Joel Stitzel, chair of biomedical engineering at Wake Forest Baptist Medical Center and an investigator in the study.

“It’s not uncommon for someone who’s sustained a mild concussion to go right back out,” says Stitzel.

Studies on professional athletes and others have shown that repetitive concussions make people more vulnerable to chronic neurological problems, says Gerry Gioia, a pediatric neuropsychologist at Children’s National Medical Center in Washington, D.C., who is also involved in the youth study. Perhaps more concerning is the possibility that blows that aren’t strong enough to cause a concussion can also cause serious injury. “There is preliminary data suggesting there may be a relationship to brain function,” says Gioia. But currently, these sorts of injuries can’t be identified in players, says Alex Powers, a pediatric neurosurgeon at Wake Forest also involved in the study.

The researchers worked with two youth teams and one high school team over the 2012-2013 football season. With helmets instrumented with accelerometers to measure head impacts, the researchers recorded more than 16,000 impacts over the course of that season. The researchers also gave the players neurological tests and brain scans using magnetic resonance imaging and magnetoencephalography to look for changes in the brain before and after the season.

The risk of concussion accumulated over a season was calculated from the frequency and size of all impacts on each player. Most of the hits were below the range of impact associated with a concussion, but “when you look at the total risk that a player sustains over the course of the season, those risks can be the mathematical equivalent of two to three concussions,” says Stitzel.

Whether head hits that don’t cause a concussion are a problem is not yet clear, says Joseph Maldjian, director of the Advanced Neuroscience Imaging Research Laboratory at Wake Forest. “It may turn out that there are changes happening inside the brain, or maybe there is no effect unless you get that serious concussion,” Maldjian says.  

Ultimately, the researchers hope their study can help make football safer. For instance, they found that the majority of cumulative head injury risk occurs during practices. Perhaps players could avoid high impact plays during practices. Or perhaps high-tech helmets could alert coaches when a player needs to be benched, says Powers: “I hope that one day we will be able to have a sensor in each helmet and come up with a metric that says … this player has a chance of having an injury, they need to stop and have a battery of tests.”

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Credit: Photograph by Cagney Gentry | Wake Forest Baptist Medical Center

Tagged: Biomedicine, concussions, traumatic brain injury, football, brain scans, head trauma, NFL

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