WASHINGTON -- Young athletes should visit sports medicine specialists when injured, new research shows playing football could cause chronic traumatic encephalopathy (CTE), and the age that kids should be permitted to play tackle football remains up for debate.
That's according to physicians who spoke at the Aspen Institute's summit here Thursday. Two panels featured Robert Cantu, MD, a neurosurgeon with Boston University's and the , and Andrew Peterson, MD, a sports medicine specialist at the University of Iowa. Other panelists included former NFL players Dominique Foxworth and Chris Borland, and physicians in the audience also addressed issues.
While panelists were charged with debating whether youth football will largely shift from a tackle to flag format in the future and any implications, the issue of brain injury including CTE came to the fore. Many researchers believe CTE is caused by the repeated minor blows to the head that occur on every football play.
"We want all contact sports to be safer," said Cantu, who helped devise sports concussion published last year. But since roughly 2008, "every experience we've had with the BU group has only fueled [concern about football]." He had previously criticized one of the consensus statements last year for his colleagues' refusal to link contact sports and CTE, and for omitting CTE animal and case studies from their review.
At the Aspen Institute event, Cantu cited a published last week, in which examination of brains from eight young athletes and animal models indicated CTE can occur solely from "subconcussive" blows.
It's possible to make football and other contact sports safer by improving coaching techniques and education to chiefly "remove the head from the game," Cantu said Thursday. But, he added, "I want very much for football to be played in a safer form. I think that safer form is flag."
Cantu worries about the consequences of football in its current form going the way of boxing -- a once-popular sport that now draws mostly from lower socioeconomic classes. Many educated and wealthier people are banning their children from playing football to avoid brain injury. If this trend continues, far more kids from low-income, less-educated families would proportionally suffer brain trauma "and set them up for cognitive impairment" leading to anxiety, depression and more serious health problems.
During his presentation, Cantu listed more than a dozen NFL standouts who never played organized football before high school. "There's not a single academic study that proves" playing before the age of 14 correlates with career success, said Cantu, who pushed USA Football -- the umbrella organization that sets national youth guidelines -- to call for leagues to ban tackle football for kids under 14.
USA Football is examining whether to set such a standard, said director Scott Hallenbeck. But the organization is awaiting research -- unlike USA Hockey and US Soccer, which recently banned checking and heading, respectively, for younger players, although there's little hard evidence that such bans would reduce head injuries.
"We're going to have to follow the science, period," Hallenbeck said. He noted USA Football has already changed other rules and guidelines "at every level," although he acknowledged it is not acting as fast as some would like.
In one exchange, Hallenbeck wondered why many critics point to the NFL as a source of football's safety problem. Cantu replied, "They've got billions and they're funding research and they are funding USA Football." Experts have critiqued these arrangements, and a 2016 MedPage Today analysis found the league was involved in a CDC youth sports safety program whose internal evaluations and success were questioned by independent researchers.
Crystal Dixon, after being paralyzed in a youth football game, called the preseason physical exams players must undergo "a joke." Parents should take their kids to physicians independent of their teams, she suggested, noting many practitioners who administer the group physicals "don't know if these kids' bodies are ready." Her son faced a higher risk of paralysis when he began playing, for example, which was not revealed until after he was injured.
Too many physicians are not aware of the updated concussion guidelines and many cannot recognize possible symptoms, said Rebecca Rodriguez, DO, a family medicine specialist with San Diego Sports Medicine. They often then allow kids to return to play before they have healed, sometimes leading to more and worse brain injuries.
Kids should see sports medicine specialists after they suffer a suspected concussion, Rodriguez told MedPage Today. She recommended educating parents about the difference between these specialists and other pediatricians and family medicine doctors. Rodriguez also recommended standardized training for all practitioners caring for youth athletes, including pediatrics, family medicine physicians and ER doctors. "Because they're going to come across [brain injuries]," she said.
Speaking during a second panel, Peterson noted that longitudinal studies are needed to draw conclusions regarding the subconcussive blows and CTE. But "it is a real issue," he added, calling the animal model studies and studies of former NFL players "good data." In addition to the Boston University work, he told MedPage Today that William Meehan, MD, of Boston Children's Hospital, has been presenting an unpublished animal-model CTE study at conferences. Both "could be really useful for informing this," said Peterson, who led a study published last year indicating that flag football isn't completely benign.
Gerard Gioia, PhD, a pediatric neuropsychologist with Children's National Health System, said researchers are struggling with extrapolating findings from NFL professionals to youth players. Gioia rejected the under-14 ban, calling it "too black-or-white." Instead he called for devising tests to determine when individual kids are developmentally prepared to play tackle football.
While the researchers debated, the two former NFL players both said they oppose youth tackle football. Foxworth, former president of the NFL Players Association, said he will not allow his son to play. Borland said that if the point of youth sports is to develop mind and body, "I don't know why youth tackle still exists."
Borland also questioned a 2015 American Academy of Pediatrics position statement on tackling in youth football, which argued against a ban in part because the authors concluded coaches can teach safer techniques. Said Borland: "There's no way to do it entirely safely."