The long-term brain health implications of contact sport participation have been intensely studied as far back as the first description in 1928 of cognitive and neuromotor changes in professional boxers by Martland1 in JAMA. Contact sports, including US football, expose athletes to traumatic injuries such as concussion. Repetitive head trauma has drawn particular concern for increased risk of later cognitive, mental health, and neurodegenerative disorders. There is controversy in the literature, because many reports have correlated repetitive concussions in football with neurodegenerative disorders such as amyotrophic lateral sclerosis or chronic traumatic encephalopathy,2 and others have identified no such association.3 Furthermore, other reports have identified alternative risk factors (eg, obesity), whereas others did not account for known contributors to neurodegenerative disease (eg, drug abuse, physical inactivity, poor sleep, poor nutrition, and mental health disorders).4
In JAMA Network Open, Roberts et al5 expand our understanding of the association of preexisting brain health conditions with response to concussion injury and risk for future cognitive decline in football players. The authors conducted a cross-sectional analysis of data from the Football Players’ Health Study (FPHS), an ongoing longitudinal cohort study of former National Football League (NFL) players, and found an association between adverse childhood experiences (eg, physical and emotional abuse, neglect, food insecurity) and concussion symptoms during playing careers and dementia symptoms in later life among former NFL players. Specifically, players with at least 4 adverse childhood experiences had double the risk of severe concussion symptoms during their careers and had a 32% increase in risk of a positive dementia screening result and a 47% increase in risk of poor cognition-related quality of life after their playing careers, irrespective of concussion history.
Strong evidence supports the association between an individual’s brain health history and response to brain trauma. For example, people with a history of migraines have headaches after concussion; individuals who get car sick have high rates of vestibular dysfunction after concussion.6 Restated simply: you injure the brain you have. Roberts et al5 make a strong addition to the literature that athletes with a history of psychological trauma or a mental health disorder are at greater risk of psychological manifestations of concussion compared with athletes without such history.
Cognitive decline, mental health disorders, and neurodegenerative disease in former athletes are multifactorial problems. Although physical brain trauma has been the focal point of this area of research, psychological trauma may be just as relevant to the development of long-term brain health issues. As the authors acknowledge, psychological trauma is associated with poorer cognitive function and mental health and increased risk of dementia in other populations. The findings of Roberts et al5 extend the associations between childhood psychological trauma and positive dementia screening results, poorer cognition, and higher rates of depression to the former NFL player population. The data reiterate how a person’s medical and psychosocial history can shape long-term brain health.
It is important to interpret the findings by Roberts et al5 within the context of some limitations. As with all survey data where participants self-report medical histories, recall bias may have occurred. The concussion definition in their study was not restricted to diagnosed concussions but included all possible concussions. As the authors point out, the rate of dementia screening was higher than in the average population and may reflect bias of the participants toward reporting a higher symptom burden given the extensive publicity associated with this topic. There are some additional covariates of cognitive decline and/or neurodegeneration that have garnered little to no attention in this area of research but are worthy of future investigation. Perhaps most importantly, drug and alcohol abuse, current prescription medications, and drug and medication use during playing years and beyond may be a crucial covariate to better understand these issues among former professional football players. A player’s postfootball prospects, both professionally and personally, may also have a direct impact. For example, players who lack an education or a postfootball financial plan may have an increased risk for mental health issues and/or poorer quality of life. Certain personality characteristics, such as self-perception of value or personal interests outside of football, may also be associated with poorer long-term psychosocial outcomes.
Behavioral health practices (eg, increasing physical activity, improving diet and sleep hygiene) are modifiable factors that can improve physical function and protect against mental health and neurodegenerative disorders. Although long-term brain health issues in former NFL players may receive disproportionate attention, these issues are not limited to football; mental health disorders occur in 16% to 26% of former elite athletes in a wide variety of sports.7 Screening and early intervention for the myriad comorbidities associated with cognitive impairment and neurodegeneration may improve long-term brain health in contact sport athletes. The screening tools used by Roberts et al5 are freely available, assess a variety of domains related to these impairments (ie, adverse childhood experiences, cognition-related quality of life, depression, anxiety, and pain), and require less than 15 minutes to complete. Longitudinal assessment of athletes who play contact sports, as in the FPHS, during their playing careers and serially thereafter will provide invaluable information regarding the timing and causality of long-term physical and psychological health issues. The data and inferences gained from such efforts will benefit athletics at all levels. As athletes injure the brain they have, we must also attend to preexisting psychological health to guide screening, prevention, and intervention practices for brain health.
Published: March 22, 2022. doi:10.1001/jamanetworkopen.2022.3305
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Eagle SR. JAMA Network Open.
Corresponding Author: Shawn R. Eagle, PhD, Department of Neurological Surgery, School of Medicine, University of Pittsburgh, 3550 Terrace St, Pittsburgh, PA 15261 (email@example.com).
Conflict of Interest Disclosures: None reported.
Eagle SR. Association of Childhood Psychological Trauma With Risk for Positive Dementia Screening and Depression in Former Professional Football Players—You Injure the Brain You Have. JAMA Netw Open. 2022;5(3):e223305. doi:10.1001/jamanetworkopen.2022.3305
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