Football-Induced Brain Damage, Not Just an NFL Problem.
Thursday, December 7, 2017
This is the final installment of the Richmond Times-Dispatch's series exploring the topic of brain injuries among high school football players.
Jacob Williams, a junior at Deep Run, stopped playing football after a concussion during his freshman season caused him to feel symptoms for eight weeks. He is not the only local player to hang up his football cleats after a severe concussion.
Discussions surrounding brain trauma and the future of football typically focus on the National Football League, which has fewer than 2,000 players on active rosters. Meanwhile, more than 1 million teenagers play high school football every year.
Football-induced brain damage is not just an NFL problem.
With researchers just beginning to quantify football’s impact on the brain, the Richmond Times-Dispatch's series explores the topic of brain injuries among high school football players. In this five-part series, we've shown the potential short- and long-term effects of brain injury for high school football players, and how those effects are discussed and handled in Richmond-area high schools. This is the final installment of their series.
As a freshman, Jacob Williams joined Deep Run High School’s football team.
Football was familiar to him — he had played every year since third grade.
During the second game of his freshman season, Williams took the field as his team prepared to receive a kickoff from opponent Henrico High School. His job was to block.
On the kickoff, Williams was blindsided by a helmet-to-helmet hit.
“Initially, I didn’t feel the symptoms,” he said. “I just felt like I got my bell rung. It felt like something normal.”
Williams shook off the hit and played a few more plays throughout the rest of the game.
The next day, he suffered from a terrible headache during practice. He approached a coach to tell him how he was feeling and was pointed to the team’s athletic trainer, who then made Williams an appointment with a physical therapist at the Bon Secours Washington Redskins Training Center.
The physical therapist told him to stay in a dark room and avoid activity, including school, for at least a week, Williams said. After going back to school, Williams said it took about two weeks to return to full academic strength.
He felt symptoms, mostly sensitivity to light, for about eight weeks. As a result, he missed eight games.
When his freshman season ended, he decided his football career would, too.
Williams’ decision to walk away from football was largely based on recent studies into chronic traumatic encephalopathy (CTE), the degenerative brain disease found in many former football players that can lead to mood swings, dementia, and has been linked even to suicide.
“I see all these terrible things in the news about these guys losing it because of CTE, and I thought maybe even that one concussion could mess me up a little bit,” he said.
Dr. Ann McKee, director of the Boston University CTE Center, announced in July that she found CTE in 110 of 111 former NFL players and three of 14 former high school players. Though her findings came from a very biased sample, her work was some of the first to suggest a potential link between CTE and high school football.
Out of fear that CTE could lead to debilitating mental and emotional symptoms, Williams stopped playing football. He now has plans to play varsity basketball at Deep Run.
“I mostly was concerned with school and just being able to grow up and not have those symptoms that those guys have in the NFL,” Williams said. “A series of those hits could really mess me up further.
“I just wanted to think about the future.”
Trinity Episcopal player Jackson Fuller (right) is examined immediately following a concussion he suffered during his sophomore season in 2014. Now a freshman at Hampden-Sydney, Fuller still feels some lasting symptoms.
As football participation continues to decrease — public high school teams in Virginia had an 8 percent drop in participation, or 2,036 fewer players, between 2012 and 2016 — incidents such as Williams’ continue to occur in the Richmond area.
Multiple Richmond-area high school football players’ parents said their sons suffered concussions on the field in recent years that led to long-term cognitive and behavioral symptoms, a condition often referred to as Post-Concussion Syndrome.
Jackson Fuller, a 2017 graduate, suffered a concussion similar to how Williams did. During his sophomore season at Trinity Episcopal in 2014, Fuller was blindsided on a kickoff and immediately stumbled to the sideline, using the 50-yard line to guide him.
“My pants were white, and they looked neon yellow to me,” Fuller said. “It was completely crazy. … I couldn’t open my eyes without getting a terrible headache.”
For about a year and a half, Fuller was not himself, said his father, Wayne Fuller.
After missing three weeks of school because of the concussion, Jackson returned to find that he was still highly sensitive to sound and light. He couldn’t bear to sit in the auditorium for school gatherings because the rumbling of his classmates chatting was like nails on a chalkboard, he said.
Jackson also dealt with mood swings, uncharacteristic irritability and moments of anger, he said. During the spring of 2015, Jackson played lacrosse, his primary sport, and got ejected from a few games for fighting.
“He was getting into fights on the field,” Wayne Fuller said. “Just uncharacteristic of Jackson.
“He was like a zombie. He was not the Jackson that we knew.”
In the fall of his junior year, Fuller returned to the football team, but decided after a hit in practice a few weeks into the season that he didn’t want to play football anymore. He chose to focus on lacrosse, which he now plays as a freshman on Hampden-Sydney’s club team.
During the spring of his junior year, about 18 months after his concussion, Jackson became himself again, his father said. Jackson’s mother, Courtney Fuller, can point to a single day when she noticed her son was himself again, Wayne Fuller said.
“From that day on, then it was almost like leaps and bounds,” the father said. “Every day got better.”
Jackson said he still doesn’t feel 100 percent, but his mental health is still gradually improving. He said his main lasting symptom has been short-term memory loss.
“I’ll be talking to somebody and, mid-conversation, forget what I’m talking about,” he said. “That happens four to five times a day.”
Other parents and players in the Richmond area described experiences similar to Fuller’s, but declined to be a part of this article.
Godwin's Claire Franks heads the ball against Deep Run's McKenna Maier in 2016. Soccer, especially on the girls side, has raised increasing concern because of its high rate of concussions.
As fewer students elect to play football, the number of athletes opting for sports such as lacrosse, as Fuller did, and soccer are increasing. During the last five years in Virginia’s public schools, boys lacrosse participation grew 24 percent and boys soccer grew 5 percent.
Although soccer’s numbers are rising in Virginia, some local football coaches think the world’s version of football may be more hazardous to its players’ brains than American football.
A study from March, performed by the American Academy of Orthopaedic Surgeons, suggested that concussion rates were higher in girls soccer than in boys football in U.S. high schools between 2010 and 2015.
The study also said that girls soccer had the highest concussion rate of any sport during the 2014-2015 school year.
Football coach Patrick Kane, who resigned Wednesday after 17 years, said soccer is cause for concern because the sport involves the technique of heading the ball, which is taught by coaches and leads to a number of brain injuries.
“Rules have been changed in football to help protect, trying to keep the head out of the game,” Kane said. “But here’s a strategy that is coached and told to do that is in direct contrast to understanding how concussions are created.”
U.S. Club Soccer has attempted to limit or eliminate heading among young players. The organization sent a mandate in 2016 to all teams under its power that players under age 11 are not allowed to head the ball in practices or games, and players 13 and younger should not head the ball more than 15-20 times during a week of practice.
Beyond concussions, soccer has not generated the same concern as football with regard to long-term brain damage. CTE has not yet been closely linked to soccer careers.
One study from doctors at University College London confirmed CTE in four of 14 former professional soccer players with an average playing career of 26 years. But the lead researchers said the risk is extremely low for recreational soccer players, and the study is no more than a first step because of its small, biased sample of players in whom dementia was previously diagnosed.
The focus of leading CTE researchers, like McKee at Boston University, remains on football. Until more soccer players elect to donate their brains to be studied for CTE and long-term brain damage, the long-term dangers of soccer will remain largely unknown.
VCU's Dr. David Cifu is leading a $62 million consortium that is researching brain trauma in military members, which is closely related to research into how football affects its players' brains.
As high school athletes continue to suffer concussions, large-scale local research is looking into ways to better handle mild traumatic brain injuries, the scientific term for concussions.
David Cifu, chairman of VCU’s Department of Physical Medicine and Rehabilitation, is directing a $62 million nationwide consortium studying the long-term effects of mild traumatic brain injury in military members and veterans. Though the study is not directly tied to football, it will help to show how concussions should be handled and what the effects really are, Cifu said.
For one, Cifu’s research program is trying to find ways to eliminate the self-reporting aspect of concussions. The best way doctors currently know to diagnose concussions is to ask someone what symptoms they are feeling, he said.
“Is there some way we could actually know what’s going on with a person in the brain, without asking them?” Cifu asked. “That’s actually the billion-dollar question.”
Cifu’s research is also working to find the most effective methods for treating concussions. Though widely accepted among many athletic trainers and doctors, the current techniques for treating concussions in high school athletes may not be what are actually best for players.
As was the case for Williams and Fuller, players are often told to sit in a dark room and avoid any activities that involve physical or mental rigor, Cifu said. Rest is almost always prescribed.
But Cifu said rest is not always the answer. Although exposure to further brain trauma should be avoided, he said, his group’s research has shown that active cognitive rehabilitation will typically serve concussed people better than inactivity.
The lack of agreement between Cifu and many high school athletic trainers and doctors shows that even concussions, which have been discussed and studied for decades, have not yet been fully figured out.
Dr. David Ross (left) pioneered NeuroQuant software, which measures brain volume change over time. His most famous test subject so far is Willie Lanier, a hall of fame linebacker.
While Cifu aims to better understand brain injuries, another doctor in the Richmond area is working to detect them.
David Ross, a neuropsychiatrist based in Midlothian, has helped to develop technology that he believes can tell high school athletes how their sport might be affecting their brain in real time.
Ross, director of the Virginia Institute of Neuropsychiatry, uses a software duo called NeuroGage, which he helped to develop, and NeuroQuant to use MRI data to measure the brain volume of people who have suffered traumatic brain injuries.
“The more severe your brain injury, the more your brain shrinks,” Ross said.
The technology can be used on high school athletes before and after a season of play to determine how their brain might have changed as a result of the hits they suffered while playing their sport, Ross said.
“The question is, did the brain shrink from before to after the season?” he said. “If not, you would feel more confident in letting this player continue to play next season.”
The tests are too new and too expensive to be used widely at this point among Richmond-area high school athletes. But Ross said he feels his work is filling a gap in the conversation surrounding subconcussive hits — those that don’t cause concussions but can still accumulate to brain damage — in football and CTE.
“There’s a big gap in knowledge between getting concussions or subconcussions and then many years later, getting CTE,” Ross said. “What if there are a lot of athletes who didn’t get CTE but maybe their IQ drops 5 or 10 points, or they’re just a little more moody and irritable all through their life?
“With brain volume or other measures that are coming along, we might help to monitor what’s really going on here.”
To date, Ross’ most famous testing subject for his software is Willie Lanier, a Richmond native and NFL Hall of Famer. Ross recently tested Lanier’s brain for abnormalities and found that it was remarkably healthy — especially considering Lanier is 72 years old.
Lanier spent 11 years as an NFL linebacker. After suffering a subdural hematoma — a type of bleeding in the brain — during his rookie season, he adjusted his approach. Lanier earned the nickname Honey Bear after changing his tackling style, which he said combined knowledge of his opponent with a leverage-based technique to minimize injuries and hits to the head.
Lanier’s subdural hematoma led him to be more conscious about his health and how he approached everything in his life, including football, he said. His tests suggest that people can play football for a long time and, if approached the right way, can end up without significant health issues.
Lanier said he has no major health problems as a result of his career.
Ross and Lanier hope the NeuroQuant and NeuroGage technology can help advance the conversation surrounding football’s dangers to the brain, ultimately leading to players at all levels being more conscious about their health before they ever suffer brain damage.
“My only reality was (brain damage) does not have to be a part of the game,” Lanier said.
Beyond Richmond, research such as McKee’s at the Boston University CTE Center is finding increasing evidence that football careers can chronically damage players’ brains.
Aside from McKee’s blockbuster CTE findings released in July, she and her colleagues have found other evidence suggesting football can alter the brains of players at or below the high school level.
Dr. Robert Cantu, co-founder of the CTE Center and the Concussion Legacy Foundation, said kids are especially at risk for brain changes between the ages of 10 and 12.
“If you have brain injury at that age, (your genetic makeup) can be altered, and you aren’t necessarily going to be the person you were born to be,” said Cantu, a neuropathologist.
Furthermore, Boston University researchers announced in a September study in the journal PLOS ONE that they discovered a key biomarker of CTE, a protein called CCL11. This finding was the first major step toward being able to diagnose CTE in living patients.
Currently, diagnosing CTE requires the identification of tau proteins in an athlete's brain, which can be done only after death by slicing the brain open.
On Nov. 15, researchers in Chicago reported that they detected evidence of CTE in a living patient for the first time.
“We definitely need to be able to diagnose it in living people so that we can stop people from the behavior, hopefully at a stage where it’s not progressed very far,” Cantu said.
Though Cantu, McKee and their colleagues are starting to understand the dangers for kids at the youth and high school levels, many questions are still unanswered.
For one, it remains unclear how genetic and lifestyle factors might affect the onset of CTE in former players.
“It’s probable that there are genetic factors that predispose certain people to develop it and probably genetic factors that protect other people from getting it,” Cantu said.
“We also don’t know if there are other factors, nutritionally or environmentally, that also accelerate the disease.”
VCU’s Cifu agrees that factors outside of repetitive brain trauma could potentially reduce the risk of developing brain diseases such as CTE, Alzheimer’s and dementia. High cholesterol, inactivity, stress, poor socialization and poor sleep are some issues Cifu believes could cause or accelerate brain problems.
“If we treated those things, you would lower your risk to the point where you wouldn’t even see this difference (before and after playing football),” he said.
Another question surrounding CTE is how much brain trauma it takes for the disease to develop.
Evidence has showed that more hits to the head typically increase the risk of the disease, but an approximate number of hits has yet to be determined.
“It’s probable that we will one day be able to say it’s relatively safe to play this number of years, and it’s probably going to be more than one year and probably less than 10,” Cantu said. “We don’t know what that critical window is that you might be able to play without any increased risk.”
Chris Nowinski, who co-founded the Concussion Legacy Foundation and CTE Center with Cantu, said the Center now has hundreds of brains to study, which could lead to figuring out how genetics, nutrition and other factors affect the onset of CTE within the next few years.
Alex Motley grabs tickets at the entrance of the Hermitage v. Highland Springs game in August. The revenue high schools make from football games is a huge factor in their athletic budgets.
Brain-injury research may be advancing, and fewer Virginia athletes may be choosing to play football in high school, but football programs have endured.
Despite the 8 percent decrease in football players over the past five years, the number of high school football programs in Virginia has increased as new schools have opened. Five more public high schools offered football in 2016 than in 2012.
Public high schools rely on their football teams for much of their athletic budgets. The revenue that schools make from ticket sales pays for softball uniforms, buckets of baseballs and soccer officials.
“It’s historically your biggest fall sport, it’s a community involvement thing, it’s a school pride thing,” said Rob Welch, Henrico High’s student activities director.
Title IX regulations are another reason football programs are surviving through increased brain-injury awareness and a drop in participation, Welch said.
The number of students playing football in 2016 was more than double those who played soccer, the next most popular male sport. As schools try to balance athletic participation between boys and girls sports, football carries a tremendous weight on that scale.
If a high school decided to cancel its football program, it would need to offer other boys sports or eliminate girls sports to fill the large gap in participation left by football.
Until participation falls much more drastically than it is currently, Welch believes high school football programs are here to stay.
“I don’t think you’ll see teams dropping football unless they just don’t have enough kids coming out,” he said.
“I think you’ll have some form of football that’ll always be played in America. There’s just too much of a tie to it.”
As research continues to advance, players such as Williams at Deep Run will become increasingly aware of the risks that football can present. New tackling techniques and lighter practice schedules may be making the game safer, but the risk football poses to its players’ brains will continue to drive some athletes to choose other sports.
Cantu is on the side of players like Williams. Rather than play football until research shows exactly how dangerous it is, Cantu said players should do the opposite.
“Until we know what level of banging of the head is safe, which we don’t now, it seems to me you shouldn’t be doing it,” he said.