Title of Presentation

Presenter’s namePresenter’s title

Age at first exposure to repeated head impacts & long-term risks

Robert C. Cantu, MA, MD, FACS, FACSM, FAANS

Clinical Professor of Neurosurgery and NeurologyCo-Founder-Clinical Diagnostics and Therapeutics

Leader CTE-AD CenterBoston University School of Medicine

Medical Director and Director of Clinical ResearchDr. Robert C. Cantu Concussion Center

Assoc. Chairman, Dept. of Surgery, Chief, Neurosurgery ServiceDirector of Sports Medicine

Emerson Hospital, Concord, MA

Medical DirectorNational Center for Catastrophic Sports Injury Research

Adjunct ProfessorDept. of Exercise and Sports Science, UNC Chapel Hill

Co-Founder, Medical DirectorConcussion Legacy Foundation

Member Independent Concussion Advisory GroupWorld Rugby

Senior Advisor, NFL Head Neck & Spine Committee

Member, NFLPA Mackey-White TBI Committee

Senior Advisor Brain Injury CenterChildren’s Hospital, Boston MA

VP and Chair Scientific Advisory CommitteeNational Operating Committee on Standards for

Athletic Equipment ( NOCSAE )

Senior Advisor NFL Head Neck & Spine Committee

VP NOCSAE and Chair Scientific Advisory Committee

Co-Founder, Medical Director Concussion Legacy Foundation

Royalties Houghton Mifflin Harcourt

Legal Expert Opinion (NCAA, NHL etc.)

National Collegiate Athletic Association Studen-Athlete Concussion

Injury Litigation (Medical Science Committee)

Disclosures

Consider that children compared to adults have:

1. Brains that are still developing – lack of myelination, less strength, nerve fibers more easily torn

2. Brains that are more sensitive to the excitotoxic shock of concussion (Second Impact Syndrome)

3. Weak necks that don’t distribute force to the body well plus poor head/body ratio – human bobble-head that increases risk of injury to brain and neck

4. Lighter brain than adults so less inertia more acceleration for given force

5. Weak torsos that don’t keep the head from hitting the ground

6. Poor equipment

7. Poor language skills to alert coach to concussion symptoms

8. Poor access to medical resources

9. Coaches with various levels of training

10. NO INFORMED CONSENT

Consider that children compared to adults have:

Peer Reviewed Literature Indicates:

• Developing brain is more vulnerable to poor outcome after TBI

(Giza 2005 Behavioral Brain Research)

•After TBI children vs adults have:

Prolonged recovery rates

(Lovell 2004 AJSM) (Guskiewicz 2011 PM&R)

(Field 2003 J Ped) (Anderson 2011 Brain)

(Moser 2005 Neurosurgery)

(Sim 2008 J Neurosurg)

• After TBI children vs adults have:

Altered educational and social development

Peer Reviewed Literature Indicates:

(Gioia 2009 BJSM)(Moser 2005 Neurosurgery)

Lower IQ and grade point average

(Anderson 2011 Brain)

(Gioia 2009 BJSM)

(Moser 2005 Neurosurgery

Baugh CM

Daneshvar

DH

Breaud AH

Robbins CA

Riley DO

Martin BM

McClean MD

Au R

Gioia G

Chaisson CE

Ozonoff A

McKee AC

Nowinski CJ

Cantu RC

Tripodis Y

Stern R

▪Relationship between age of first exposure to tackle football and later life mood, behavior,

and cognition.

▪

International Brain Injury Association World Congress, San Francisco, CA. March 2014

▪

92 male former foot ball players with history of no other contact sport

taken from longitudinal examination to gather evidence of neurodegenerative disease

(LEGEND) study at BU-CSTEself report and online data collection through online questionnaires

and telephone ▪ International Brain Injury Association World Congress, San Francisco, CA.2014

March 2014. interview

Relationship Between Age of First Exposure to

Tackle Football and Later Life Mood, Behavior,

and Cognition

Bourlas, AP, Stamm JM, Baugh CM, Daneshvar DH, Breaud AH, Robbins CA, Riley DO, Martin BM, McClean MD, Au R, Gioia G, Chaisson CE, Ozonoff A, McKee AC, Nowinski CJ, Cantu RC, Tripodis Y, Stern R

First study to find an association between

the age at which children begin playing

tackle football and later-life mood, behavior,

and cognitive dysfunction.

Conclusions and Relevance:

Neurology 2015; 84:1-7

Neurology 2015; 84:1-7

Second study to find an association between the age at which children begin playing tackle football and later-life cognitive dysfunction.

Conclusions and Relevance:

Key Points:

• Question: Is younger age of first exposure (AFE) to American football

associated with worse long-term neuropsychiatric and cognitive function?

• Findings: Among 214 former amateur and professional football players, AFE

to football before 12 corresponded with worse and >2X increased odds for

clinically-meaningful impairments in reported behavioral regulation,

depression, apathy, and executive function, compared to those who began

playing ≥12. Effects were independent of duration of play, and were not level

of play dependent. Significant relationships with clinical measures were

present when AFE was examined as a continuous variable.

• Meaning: Youth exposure to football may have long-term neuropsychiatric

and cognitive consequences.

Third paper from our BU group showing greater chance to

develop later life cognitive, behavior/mood symptoms in

athletes who start playing tackle football under age 12.

Age of First Exposure to Tackle Football and

Chronic Traumatic Encephalopathy

Michael L. Alosco, PhD, 1 Jesse Mez, MD, MS,1 Yorghos Tripodis, PhD, 1,2 Patrick T.

Kiernan, BA, 1,3 Bobak Abdolmohammadi, BA,1 Lauren Murphy, BA,1 Neil W.

Kowall, MD, 1,4,5 Thor D. Stein, MD, PhD, 1,4-6 Bertrand Russell Huber, MD, PhD, 1,5

Lee E. Goldstein, MD, PhD, 1,4,7,8 Robert C. Cantu, MD,1,9-11 Douglas I. Katz, MD,1,12

Christine E. Chaisson, MPH, 1,13 Brett Martin, MS,1,13 Todd M. Solomon, PhD,1

Michael D. McClean, ScD,14 Daniel H. Daneshvar, MD, PhD,1,15 Christopher J.

Nowinski, PhD,1,10 Robert A. Stern, PhD,1,9,16 Ann C. McKee, MD1,4-6

ANNALS OF NEUROLOGY 2018

Age of First Exposure to Tackle Football and

Chronic Traumatic Encephalopathy

• 246 tackle football players who donated brains-211 with CTE (126/211 without

comorbid disease, 35 without CTE

Results

• Age of exposure not associated with CTE severity or Alzheimer’s disease

• Of 211 with CTE every year younger participants began playing football

predicted earlier reported cognitive symptoms onset by 2.44 yrs. and

behavior/mood symptoms by 2.5 yrs. (p<0.0001)

• Age of exposure before 12 predicted earlier cognitive and behavior/mood

symptoms by 13 years (p<0.0001)

Age of First Exposure to Tackle Football and

Chronic Traumatic Encephalopathy

• Fourth paper from our BU group showing greater

chance and in this case earlier onset of cognitive,

behavior/mood symptoms in athletes who start

playing tackle football under age 12.

Stamm JM

Koerte IK

Muehlmann M

Cantu RC

Stern RA

Shenton ME

Age at first exposure to football is associated with altered corpus callosum white matter microstructure in former professional football players.

Journal of Neurotrauma 2015 ePubahead of publication. PMID:26200068

Age at First Exposure to Football Is Associated with Altered Corpus Callosum White Matter Microstructure

in Former Professional Football Players Julie M. Stamm,1–3 Inga K. Koerte,3,4 Marc Muehlmann,3,4 Ofer Pasternak,3,15 Alexandra P. Bourlas,1,5

Christine M. Baugh,1,6 Michelle Y. Giwerc,3 Anni Zhu,3 Michael J. Coleman,3 Sylvain Bouix,3 Nathan G. Fritts,1

Brett M. Martin,7 Christine Chaisson,1,5,7,8 Michael D. McClean,9 Alexander P. Lin,3,10 Robert C. Cantu,1,11–13

Yorghos Tripodis,1,5,8 Robert A. Stern,1,2,5,11,14,* and Martha E. Shenton3,15,16,* Abstract

Youth football players may incur hundreds of repetitive head impacts (RHI) in one season. Our recent research suggests that exposure to RHI during a critical neurodevelopmental period prior to age 12 may lead

to greater later-life mood, behavioral, and cognitive impairments. Here, we examine the relationship between age of first exposure (AFE) to RHI through tackle football and later-life corpus callosum (CC) microstructure using magnetic resonance diffusion tensor imaging (DTI). Forty retired National Football League (NFL) players, ages 40–65, were matched by age and divided into two groups based on their AFE to tackle football: before age 12 or at age 12 or older. Participants underwent DTI on a 3 Tesla Siemens (TIM-Verio) magnet. The whole CC and five subregions were defined and seeded using deterministic tractography. Dependent measures were fractional anisotropy (FA), trace, axial diffusivity, and radial diffusivity.

Results showed that former NFL players in the AFE <12 group had significantly lower FA in anterior three CC regions and higher radial diffusivity in the most anterior CC region than those in the AFE ‡12 group. This is the first study to find a relationship between AFE to RHI and later-life CC microstructure. These results suggest that incurring RHI during critical periods of CC development may disrupt neurodevelopmental processes, including myelination, resulting in altered CC microstructure.

Key words: age at first exposure; American football; corpus callosum; diffusion tensor imaging; repetitive head

impacts

Journal of Neurotrauma

2017

Thus starting Tackle Football < 12 is associated with:

➢ Greater chance for later life cognitive, mood, & behavioral deficits

➢ Earlier onset CTE symptoms

➢Greater microstructure deficits in anterior corpus callosum

➢Smaller Thalamic Volumes

All-Time Greatest Team

• We assembled the Flag Football Under 14 All-Time

Greatest Team, composed entirely of players who did not

start tackle football until high school, to illustrate that it is

better to wait.

All-Time Greatest Team

• Dozens of other great players narrowly missed the cut for this team, including Drew Brees, Clinton Portis, Charlie Joiner, Sonny Randle, Jackie Smith, Ben Coates, Harvey Martin, Leo Nomellini, and many more.

• The team demonstrates that choosing to wait until high school did not affect the playing careers of an astonishing number of all-time great players across all positions. Waiting until high school not only was inconsequential to their success as pros, it minimized these athletes’ exposure to brain trauma.

Thank You!

Disclosures

• Senior Advisor NFL Head Neck & Spine Committee

• VP NOCSAE and Chair Scientific Advisory Committee

• Co-Founder, Medical Director Concussion Legacy Foundation

• Royalties Houghton Mifflin Harcourt

• Legal Expert Opinion (NCAA, NHL etc.)