“I feel … as sharp as I’ve ever been,” remarked a pensive 24-year-old Chris Borland. Having barely begun his NFL career, the San Francisco 49ers linebacker looked back on his two prior concussions and saw a future devastated by degenerative brain disease and an end before his time. On Monday, March 17, 2015, the promising rookie retired after only one season as a pro.
The stories are by now familiar; numerous professional and amateur athletes have died young, often by their own hand and after a sometimes well-concealed, but nevertheless inexorable, descent into cognitive, psychiatric, behavioral, social and economic ruin.
One of the saddest stories is the decline, fall and early death in 2002 at age 50 of “Iron Mike” Webster, perhaps the most outstanding center ever to play in the NFL. Webster’s brain would—eventually—open our eyes to the worst outcome of repeated head impacts. What many do not know about Webster, however, is that he was never, ever diagnosed with a concussion.
Why did Chris Borland make the undeniably brave decision to drastically change the course of his life and why is he widely admired for this move, which would have evoked scorn, derision and dismay a few short years ago? Borland may go on to success in other areas, but at this moment he has relinquished the benefits of professional sports most can only dream of. On the other hand, what has he gained? Can he rest assured he has avoided the fate of those who have disintegrated before our eyes?
Pros’ Choices and Consequences Influence Amateurs and Parents
Parents and everyday amateur athletes face a similar dilemma as they contemplate the balance between benefit and risk of collision sports such as football, hockey and lacrosse—and, yes, even soccer (one of Borland’s prior concussions was sustained playing soccer). Upsides of participation are clear: people who move more tend to live longer. Staying on the couch may avoid concussion, but it is decidedly not a shortcut to health and longevity.
Team (collision) sports also provide important venues for developing character and skills such as leadership, teamwork, tactical thinking and more. Often, however, the allure of the tangibles, which Chris Borland left behind, are what entice young people to play and hit more and harder, all in the hopes of “making it.” This draw, especially to the impulsive, developing personae of youth, often overshadows an important reality: even for a talented athlete, performance in the classroom is a much surer ticket to a secure, successful and rewarding future than the lottery-like odds of pro sports fame. Moreover, there are many noncollision, albeit less glamorous, options for physical activity. Yet our children continue to hit, head and collide, though perhaps with tempered vigor born of a nascent ambivalence. Do the risks outweigh the potential benefits? While the decision to forgo voluntary head trauma may seem like a “no brainer,” is the trade-off really so clear-cut?
Even a Mild Concussion is a Brain Injury
Concussion is diagnosed when symptoms of brain dysfunction (headache and nausea, disorientation, memory or balance problems and more) follow an impact or nonimpact force to the head. Most often, concussion symptoms last from seconds to minutes. In a minority of cases, symptoms persist for weeks. Though more than 95 percent of sports-related concussions reportedly “fully resolve,” some concussed athletes never fully recover. Notwithstanding these generally optimistic statistics, concussion does not float outside the brain on Cartesian ether; modern brain science understands that every concussion represents a physical injury to the brain. With the abatement of concussion symptoms, we hope that the brain injury itself heals or resolves. The actual evidence, however, indicates that when impacts are superimposed on a brain that has not recovered from a prior injury, its susceptibility to further injury is magnified.
Head impacts that produce only fleeting, mild symptoms, or perhaps no symptoms at all, have recently come to be termed “subconcussive”; concern is growing about the cumulative effect of multiple subconcussive impacts. Numerous such impacts might lead to significant brain injury even though any one subconcussive impact alone would not. In experimental models, in fact, brain pathology may be detected only following the second of two sequential mild impacts. My own research has shown that the more times an amateur player heads a soccer ball, even in the absence of symptoms, the greater the chances that injury will be detectable in his or her brain and cognitive function. However, the number of impacts that increase risk for the players we studied cannot necessarily be applied to other individuals, who might be more or less sensitive to a similar amount of subconcussive injury.
How Protective Are Hit Limits?
Both professional and lay advocates, notably Dr. Robert Cantu and Chris Nowinski of the Sports Legacy Institute, have nobly advocated limits on head impacts in youth sports. If, however, we eliminate contact below an age cutoff or cap contact at a certain number of hits per season, have we modified lifetime risk from cumulative subconcussive injury? Do fewer hits or later entry into the fray attenuate risk? I hope so, but what if the increase in risk with incrementally more impacts is not continuous, but embodies an exposure threshold? This threshold could be surpassed if it is lower than the limitations we place on impacts. Without understanding the nature of risk thresholds, we may in fact not actually be protecting players. To put it differently, does Chris Borland’s decision to leave the NFL after an aggressive amateur career and two recognized concussions protect him from the long-term effects of multiple hits? Or was the die already cast during his collegiate career or even earlier?
Staying in the Game: It’s a Personal Choice
We are, after all, concerned not only with protecting athletes from the horrific demise of a Mike Webster or Junior Seau, one of the greatest linebackers of all time, who committed suicide at age 43. We should strive to ensure that all young athletes reach their full intellectual potential and maintain it throughout their lifetimes. The extent to which subconcussive impacts can limit this potential is not known today; while we know that risk exists, the evidence to quantify and specifically advise on this risk does not. Extreme measures (staying home on the couch) can eliminate the risk, but this approach entails its own substantial, if not even greater, risks.
Under the shadow of this uncertainty, each individual must weigh the known and potential risks and benefits and make a personal choice. This is the message of Chris Borland’s difficult, life-altering decision, which should inspire and encourage the objective and rigorous scientific investigation that can provide definitive answers, which we can only hope for at present.