The association between concussions in American football and dementia
Concussion is typically described as a complex pathophysiological process affecting the brain, resulting from trauma or injury that is induced by biomechanical forces (McCrory et al., 2017). The impacts on the cerebrum associated with concussion can be particularly damaging and are linked to a lower life-expectancy (Gould, 2012), and can be fatal if not treated adequately (Amen et al., 2011). Each concussion is entirely unique and similarly, the side effects range significantly in different individuals. For example, cerebral pains, sluggishness, and memory loss may happen immediately, or in the days following the initial injury.
The risk of concussion is particularly high in American football players (Clay, Glover and Lowe, 2013). This increased prevalence, has meant concussions within the Nation Football League (NFL) and collegiate level football has become the centre of considerable attention since the mid 1990’s; termed by Harrison (2014) as ‘The Concussion Crisis’. In response, the principal ‘Mind Injury Committee’ was established in 1994 for the NFL (Ezell, 2020) aiming to XXXXXXX?. However, statistics for the number of the concussions in the NFL only date back to as recent as 2012, where 261 cases were recorded. A focal point and an area which received attention a century ago as a clinical issue among young individuals playing football, is now gaining attention by top universities and is currently a major issue of general wellbeing across all levels of play. The concussion rate in the NFL has diminished since 2012, although 2017 had the greatest number of cases, recording 281 competitors reported as experiencing concussions (Casson, Viano, Powell and Pellman, 2010).
Despite the relatively recent interest in concussion in football, there is evidence of early reporting of concussions back to 1883. In 1894, Penn footballer William Harvey expressed “the main genuine injury I got was in the game with Harvard in 1883”. He also made the following statement “when in a scrimmage behind the objective I was tackled, however retained awareness in around fifteen minutes.” (Harrison, 2014). DE – if this is a direct quote add the page numbers its from? This early documentation of concussion emergency in football highlights basic issues related to the type of arrangements instituted or if any arrangements were established for when these events occurred. Concussions in American football, which is a sport widely participated in among youth, secondary schools, universities, and on professional levels, is one small aspect of a much larger current issue relating to head injury in sports (Harrison, 2014).
Concussions in other sports.
When comparing the rates of concussion within football to other sports such as rugby, some fascinating results were drawn. A recent systematic review (Concussion Rate, 2020) which analysed the concussion rate in group activities, found that men’s rugby was found to have the most noteworthy rate of concussions in both match play (3.00/1,000 athletic exposure, AE) and practice (0.37/1,000 AE). These findings are not unexpected, given that as rugby players unlike NFL players do not wear any protective head gear during competitive match play or practice.
While investigating concussive head traumas within the previous 20 years, data shows that the frequency of these concussions have increased significantly (Cantu, 2006). However, it cannot be determined from these data how many of these individuals experimented multiple concussions. Macciocchi, Barth, Littlefield and Cantu, (2001) carried out a study with athletes who sustained one versus two concussions in competitive endeavours. They found that the impacts of two head collisions did appear to be greater than that of a solitary head injury. The neurocognitive and neurobehavioral outcomes of two concussions did not have all the earmarks of being essentially unique in relation to those of one concussion.
Repetitive concussions.
Despite the fact that one concussion does not seem to bring about critical dreariness (BrainLine, 2020), the impact of two or more is less clear. In an ongoing report, conducted by Collins (1999), a benchmark group configuration was utilized to look at competitors who had been diagnosed with one concussion versus with competitors who had a history of multiple concussions. They found that competitors who were diagnosed with a minimum of two concussions revealed more neurobehavioral manifestations and had more disability on neuropsychological tests than competitors who experienced a single concussion. However, there were no differences between competitors with a background of one concussion versus at least two concussions, on sound-related consideration, verbal familiarity, verbal learning, verbal memory, or fine motor dexterity (Collins, 1999). This suggests that repetitive concussions can be detrimental to an individual’s health.
McAllister et al., (2012) investigated collegiate football and ice hockey levels, comparing the outcomes surrounding non-contact and contact play on a variety of measures. Those considered contact athletes wore accelerometer-instrumented helmets and took pre- and post-season ImPACT tests. Participants completed a paper-and-pencil neuropsychological battery and also had preseason and postseason neuroimaging. Their results revealed that there was no significant difference amongst the sport groups. Previous exposure to one head trauma did not affect tests scores. However, the researchers did report that the contact-controlled group performed worse that the non-contact group on measure of new learning (California Verbal Learning Test).
Recent epidemiologic studies by McAllister and McCrea (2017) suggest that reoccurring head traumas are somewhat uncommon amongst athletes during play. However, there can be negative effects in recovery and return to play over the short-term compared with a first concussion. Additional exploration and further studies are needed as human studies of the neurologic and neuropsychological effects of repetitive impacts not associated with diagnosed concussion is currently quite limited.
Concussion and dementia
The relationship between sport related concussions and dementia is complex. Firstly, the term ‘dementia’ reflects the side effects of a significant accumulation of sicknesses which progresses into a dynamic decrease in an individual’s wellbeing. Some examples of this include the following impacts; loss of memory, astuteness, discernment, social aptitudes and physical working (Kenzie et al., 2017). Kindell, Keady, Sage and Wilkinson (2016) describe dementia as a syndrome initiated by a variety of conditions that affect the brain leading to problems with memory, language, understanding and judgment. Dementia is seminally described as a progressive condition affecting the neurological system that leads to development of cognitive deficits. It currently perceived to be progressive and incurable. In fact, the 18th century dementia was defined as lacking competence and being unable to manage personal affairs as identified in a study by Geary (2014). Dementia can have drastic lifechanging results and there is not currently a cure (Sait, 2013).
Previous research conducted by Blennow, Hardy and Zetterberg (2012) indicates that for certain athletes there might be severe and long-term effects of continuous head trauma injuries that have generally been viewed as mild. Nonetheless, it is realised that traumatic brain injury (TBIs) increase the risk of experiencing dementia, and that football players can endure TBIs all through their professional playing career (VanItallie, 2019). Dementia is a disease that may not be diagnosed immediately, until it has progressed to later stages (Geary 2014).
There is the presence of ever-increasing evidence that links sports related head injuries such as concussions to neurological problems and neurodegeneration later on in life (Dementia Four Times More Likely in Pro Football Players | ALZFORUM, 2012). Figures from the NFL show a staggeringly high proportion of players have been diagnosed with dementia (GIVE THE FIGURE) and is being identified more in players who have retired. Weir et al., (2009) compared retired NFL athletes to all US men and found that the prevalence of dementia for US men aged 30-49 was only 0.1% (diagnosed with dementia, Alzheimer’s disease, or other memory-related disease). For the age group of 50 plus for US men, 1.2% of the population were diagnosed. Comparing these figures to NFL retirees, for those aged 30-49, 1.9% of retired NFL were diagnosed with dementia or memory related disease. While in the age group of 50 plus, 6.1% of NFL retirees were diagnosed, suggesting a much higher prevalence of memory-related disease in ex-NFL players. However, there are limitations in this approach as the questionnaire used, ‘National Health Interview Survey’ is quite vague for memory related disease, making the interpretation of the questionnaire difficult. This limitation means that further research is needed to fully understand the associations between playing football and neurodegenerative diseases. However, overall, the findings highlight the detrimental impact concussions have on NFL athletes and further reinforces the importance of this area of study.
These results are not only seen in the NFL but are similar in other sports. A study conducted by Vann Jones, Breakey and Evans (2013) focused upon football athletes, and the motion of heading a football and effects on long term cognitive decline and dementia. A Test Your Memory (TYM) questionnaire was given to the athletes to fill out and their results found that, 10 of 92 respondents (10.87%) screened positive for possible mild cognitive impairment (MCI) or dementia. This shows how the problem of head injuries leading to cognitive issues is widespread across the sporting world, opposed to being limited to just the NFL alone.
Significance of work
The study into the impact concussions and the implications it causes in relational to the development of dementia has been an area of study which is greatly explored. However, the study of NFL players and how concussions they may have incurred could impact their likelihood of developing dementia is a lot more refined. This is reflected clearly in a study by Schwarz (2009) exploring the dementia risk NFL players face, reporting a clear relationship between football and dementia and other cognitive impairments. This area must be considered with great importance, especially due to the danger it poses to the athletes involved in the sport. It would be particularly important to athletes as they directly impacted by the detrimental effects. The National Football Players Association are also responsible for the wellbeing of the athletes. This could mean they would have to reinforce polices and regulations that enforce the safety of its players. This could include reviewing existing guidelines or adding new guidelines into place. Therefore, the aim of this study is to investigate the relationship between dementia and grass root level football. Previous studies have only looked a dementia above age 30, however, American football is played from grass root levels. Therefore, this work will look at earlier age groups and the implications of head injuries in relation to the early onset of dementia.
Methodology
Participants
This study will include a total of 50 semi-professional American Football players, playing in the British American Football League. The participants will be selected randomly from the London Olympians AFC team with ages ranging from 18-45. GIVE DEETS ON WHETHER ALL MALE? DIFF ETHNICITIES?
I am looking at this age group as previous studies have failed to investigate younger age-groups despite current research stating dementia starts in the early 30’s. Young athletes are engaging in the same physical activities and there is no research looking into whether head injuries relate to early-onset dementia in this group.
Prior to the study, participants will be asked to read and sign an informed consent form as well as an information sheet. They will be informed that they can withdraw at any time from the study. All participants involved will be informed that all information they provide will be confidential and not used for any other reason besides the purpose of this study.
Procedure
Qualitative data analysis involves the identification, examination, and interpretation of patterns and themes in data and determines how these Analysing Qualitative Data look for an outcome (Meriam, 1998). Participants will take part in 30-minute interview and answer open ended questions. I am using open ended questions to get a more thorough understanding of individual responses. As mentioned, before I am using this age group as there is a gap in the research which is reinforced by previous research conducted by…
Data analysis
Step 1 – is to read the transcripts. Browse through the transcripts, as a whole. Make notes about first impressions. Step 2 – Label relevant words, phrases, sentence or sections and/or something that is repeated in several places. Also, anything that is interesting in relation to the topic. This process is known and coding or indexing. A list of codes is made, and similar codes are put together to manage codes.
School of Health, Sport and Bioscience:
Application for School Research Ethics Approval
Before completing this form, applicants should read the School Research Ethics Committee Guidance Notes. Sections A to F of this form should not exceed 3 pages using 12pt font size.
A. Applicant Details
Title of Programme of Study:
“Do concussions or repetitive concussions in American football correlate to implications surrounding dementia”
Project Supervisor(s):
Adnan Chowdary
Student Name(s) and number(s):
Abraham Ekperuoh
07448968388
UEL Email address (one key contact only):
B. Project Details
Title of Project:
“Do concussions or repetitive concussions in American football correlate to implications surrounding dementia”
Duration of Project Primary Research (MUST NOT start before ethical approval has been achieved): From – To –
Project background/rationale: (no more than 200 words)
Primary Research Aim: (clearly state the main, over-riding aim of your study)
Subsidiary Research Aims: (if applicable)
C. Research Participants
Number of participants:
Fifty semi professional athletes aged between 18-40 will be recruited.
Participant Description outlining main inclusion/exclusion criteria:
All participants must be free from disease related with cardiorespiratory, cardiovascular, neuromuscular, musculoskeletal, pulmonary and metabolic disease.
How will potential participants be identified, approached and recruited?
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If Yes to any of the above questions, please explain along with actions to be taken.
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Detail the Method/Procedures used with participants and how data will be analysed (no more than 250 words):
Methodology Specific Issues
(i) Distress/Risk – if the participant may experience some distress or be put at potential risk, how would this be managed?
(ii) Working with children – if a Disclosure & Barring Service (formerly CRB) check is needed
has this been acquired? Yes / No / Not Required
(iii) Confidentiality – how will you ensure participant confidentiality is maintained?
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Yes / No / Not Applicable
(v) Standard Protocol – please state the basis and source (including reference) for your method if using a standard protocol (e.g. dosage/weight/volume/intensity levels).
- Data security and disposal
Please confirm by ticking the relevant boxes the following:-
No personal data collected (NO NEED TO COMPLETE OTHER BOXES IF THIS APPLIES).
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There will be no transfer of data to or via a third party.
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Explanation________________________________________________________
- Other Documentation
Please include the following documents with your application – tick ¨ if included
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If applicable: External agency information letter ¨
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Questionnaire/Interview Schedule/Sample questions ¨
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Pre-Test Health Questionnaire ¨
Recruitment poster/flyer/advert ¨
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If Yes, please state committee(s).
Declaration (If a group project, all group members’ names should appear)
- I have read the School guidance notes about application for ethical approval. I am aware of my responsibilities and agree to abide by them.
- I agree to inform my project supervisor and the School Research Ethics Committee of any changes to the proposed programme.
- I undertake to abide by accepted ethical principles and appropriate code(s) of practice in carrying out this research.
- I confirm that my project supervisor has read and agreed to this copy of the ethics application
NAME: …………………………………..
Date: ……………………………………
Supervisor Name ___________________________
(Supervisor must email the Committee Administrator at [email protected]
to confirm that they have read and approved this application for submission. Without this approval the application will not be reviewed)
SCHOOL OF HEALTH, SPORT & BIOSCIENCE
RESEARCH ETHICS APPLICATION RISK ASSESSMENT FORM
| Student Name/Number:
|
Brief Outline of
Research Study: |
||
| Specify Location of Primary Research: |
(N.B. – if location is not on UEL premises MUST include statement of personal safety below – see Guidance Notes)
| Hazards identified | Who might be at risk | Existing controls | Likelihood
H M L |
Severity
H M L |
Residual risk
1-9 |
Additional control measures required | Date actioned | Estimated residual risk |
KEY
| Likelihood
L. Low (seldom) [1 point] M. Medium (frequently) [2 points] H. High (certain or near certain) [3 points] |
Severity
L. Slight (less than 3 days off work) [1 point] M. Serious (over 3 days off work) [2 points] H. Major (major injury/death) [3 points] |
Residual Risk (Likelihood x Severity)
1 – 2 No action/low priority 3 – 4 Medium 6 – 9 High priority/urgent action |
Review Date |
INFORMATION SHEET FOR PARTICIPANTS
Programme of Study: Insert here
Title of Project: Insert here
(All questions in red below should be used as prompts to create complete paragraphs in lay terms so this reads as an easy to follow letter to the participant)
Dear Participant,
You are being invited to take part in a research study. Before you decide whether to participate, it is important for you to understand why the research is being done and what it will involve. Please take time to read the following information carefully and ask us if there is anything that is not clear or if you would like more information. Take time to decide whether or not you wish to take part.
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- Reason for the study
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- Outline of procedures/methods
- How long it will take
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Your participation in this study and all information collected will be kept strictly confidential. Where necessary, information collected will be coded so that you cannot be recognised from it. The results of this study will be reported as part of my degree programme and may be further disseminated for scientific benefit. The results will be available to you on request.
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CONSENT FORM
Programme of Study: Insert here
Title of Project: Insert here
Project Supervisor: Insert here
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I confirm that I have read the information sheet for the above study and I have been given a copy to keep.
I understand what the study is about and I have had the opportunity to discuss with the researcher and ask questions about the study.
The procedures involved have been explained to me. I know what my part will be in the study and how the study may affect me.
I understand that my involvement in this study and particular data from this research will remain strictly confidential. Only researchers involved in the study will have access to the data.
It has been explained to me what will happen to the data once the study has been completed.
I understand that I have the right to stop taking part in the study at any time and I am not obliged to give any reason.
I know that if I do withdraw, it will not disadvantage me.
I know who to contact if I have any questions/concerns about my participation and I have their contact details.
I fully and freely consent to participate in the study.
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| Please tick to agree
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Participant’s name (BLOCK CAPITALS)
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Date:
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References
Alzforum.org. 2012. Dementia Four Times More Likely In Pro Football Players | ALZFORUM. [online] Available at: <https://www.alzforum.org/news/research-news/dementia-four-times-more-likely-pro-football-players> [Accessed 1 April 2020].
Amen, D., Newberg, A., Thatcher, R., Jin, Y., Wu, J., Keator, D. and Willeumier, K., 2011. Impact of Playing American Professional Football on Long-Term Brain Function. Journal of Neuropsychiatry, 23(1), pp.98-106.
Blennow, K., Hardy, J. and Zetterberg, H., 2012. The Neuropathology and Neurobiology of Traumatic Brain Injury. Neuron, 76(5), pp.886-899.
BrainLine. 2020. Facts About Concussion And Brain Injury | Brainline. [online] Available at: <https://www.brainline.org/article/facts-about-concussion-and-brain-injury> [Accessed 1 April 2020].
Cantu, R., 2006. Sex Differences in Outcome Following Sports-Related Concussion. Yearbook of Sports Medicine, 2006, pp.36-37.
Clay, M.B., Glover, K.L. and Lowe, D.T., 2013. Epidemiology of concussion in sport: a literature review. Journal of chiropractic medicine, 12(4), pp.230-251.
Casson, I., Viano, D., Powell, J. and Pellman, E., 2010. Twelve Years of National Football League Concussion Data. Sports Health: A Multidisciplinary Approach, 2(6), pp.471-483.
Collins, M., 1999. Relationship Between Concussion and Neuropsychological Performance in College Football Players. JAMA, 282(10), p.964.
Collins, M., 2003. Cumulative Effects of Concussion in High School Athletes. Neurosurgery, 53(1), pp.247-248.
Complete Concussion Management Inc. 2020. What Sport Has The Most Concussions? | Concussion Rate. [online] Available at: <https://completeconcussions.com/2018/12/05/concussion-rates-what-sport-most-concussions/> [Accessed 31 March 2020].
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Ezell, L., 2020. Timeline: The NFL’S Concussion Crisis – League Of Denial: The NFL’s Concussion Crisis – FRONTLINE. [online] FRONTLINE. Available at: <https://www.pbs.org/wgbh/pages/frontline/sports/league-of-denial/timeline-the-nfls-concussion-crisis/> [Accessed 1 April 2020].
Geary, Jennifer, “A Literature Review of the Negative Impact of Dementia on the Nutritional Status of Hospitalized Elderly Patients” (2014). Honors Theses. 19. https://digitalcommons.salemstate.edu/honors_theses/19
Gould, W., 2012. Football, Concussions, and Preemption: The Gridironof National Football League Litigation. FIU Law Review, 8(1).
Harrison, E., 2014. The First Concussion Crisis: Head Injury and Evidence in Early American Football. American Journal of Public Health, 104(5), pp.822-833.
Kindell, J., Keady, J., Sage, K. and Wilkinson, R., 2016. Everyday conversation in dementia: a review of the literature to inform research and practice. International Journal of Language & Communication Disorders, 52(4), pp.392-406.
Kenzie, E.S., Parks, E.L., Bigler, E.D., Lim, M.M., Chesnutt, J.C. and Wakeland, W. (2017). Concussion As a Multi-Scale Complex System: An Interdisciplinary Synthesis of Current Knowledge. Frontiers in Neurology, 8.
Library, C., 2020. NFL Concussions Fast Facts. [online] CNN. Available at: <https://edition.cnn.com/2013/08/30/us/nfl-concussions-fast-facts/index.html> [Accessed 31 March 2020].
McAllister, T.W., Flashman, L.A., Maerlender, A., Greenwald, R.M., Beckwith, J.G., Tosteson, T.D., Crisco, J.J., Brolinson, P.G., Duma, S.M., Duhaime, A.-C., Grove, M.R. and Turco, J.H. (2012). Cognitive effects of one season of head impacts in a cohort of collegiate contact sport athletes. Neurology, [online] 78(22), pp.1777–1784. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3359587/ [Accessed 6 Jan. 2020].
McAllister, T. and McCrea, M., 2017. Long-Term Cognitive and Neuropsychiatric Consequences of Repetitive Concussion and Head-Impact Exposure. Journal of Athletic Training, 52(3), pp.309-317.
Meriam, S. (1998). Qualitative research and case study applications in education: Revised and expanded from case study research in education. San Francisco: Jossey-Bass.
N. Macciocchi, S., T. Barth,, J., Littlefield, L. and C. Cantu, R., 2001. Multiple Concussions and Neuropsychological Functioning in Collegiate Football Players. Journal Of Athletic Training, 36(3): 303–306.(PMC155422).
Sait, K., 2013. Head Injuries, Concussions And Dementia. [online] Dementia.org.au. Available at:<https://www.dementia.org.au/files/AlzNSW_Football_head_injuries__the_risk_of_dementia_final_130313_web.pdf> [Accessed 1 April 2020].
Schwarz, A., 2009. Dementia Risk Seen In Players In N.F.L. Study. [online] Livingdementia.com. Available at: <http://www.livingdementia.com/downloads/newsletters/2012/ny_times_2009_nfl_dementia.pdf> [Accessed 1 April 2020].
VanItallie, T., 2019. Traumatic brain injury (TBI) in collision sports: Possible mechanisms of transformation into chronic traumatic encephalopathy (CTE). Metabolism, 100, p.153943.
Vann Jones, S., Breakey, R. and Evans, P., 2013. Heading in football, long-term cognitive decline and dementia: evidence from screening retired professional footballers. British Journal of Sports Medicine, 48(2), pp.159-161.
Weir DR, Jackson JS, Sonnega A. National Football League Player Care Foundation Study of Retired NFL Players. Ann Arbor: Institute for Social Research, University of Michigan; September 2009 , pp.32
