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March 17, 2015; 84 (11) Article

Age of first exposure to football and later-life cognitive impairment in former NFL players

Julie M. Stamm, Alexandra P. Bourlas, Christine M. Baugh, Nathan G. Fritts, Daniel H. Daneshvar, Brett M. Martin, Michael D. McClean, Yorghos Tripodis, Robert A. Stern
First published January 28, 2015, DOI: https://doi.org/10.1212/WNL.0000000000001358
Julie M. Stamm
From the CTE Center (J.M.S., A.P.B., C.M.B., N.G.F., D.H.D., Y.T., R.A.S.), Department of Anatomy and Neurobiology (J.M.S., R.A.S.), BU Alzheimer's Disease Center (A.P.B., Y.T., R.A.S.), Department of Neurology (C.M.B., R.A.S.), and Department of Neurosurgery (R.A.S.), Boston University School of Medicine; and Data Coordinating Center (B.M.M.), Department of Environmental Health (M.D.M.), and Department of Biostatistics (Y.T.), Boston University School of Public Health, Boston, MA.
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Alexandra P. Bourlas
From the CTE Center (J.M.S., A.P.B., C.M.B., N.G.F., D.H.D., Y.T., R.A.S.), Department of Anatomy and Neurobiology (J.M.S., R.A.S.), BU Alzheimer's Disease Center (A.P.B., Y.T., R.A.S.), Department of Neurology (C.M.B., R.A.S.), and Department of Neurosurgery (R.A.S.), Boston University School of Medicine; and Data Coordinating Center (B.M.M.), Department of Environmental Health (M.D.M.), and Department of Biostatistics (Y.T.), Boston University School of Public Health, Boston, MA.
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Christine M. Baugh
From the CTE Center (J.M.S., A.P.B., C.M.B., N.G.F., D.H.D., Y.T., R.A.S.), Department of Anatomy and Neurobiology (J.M.S., R.A.S.), BU Alzheimer's Disease Center (A.P.B., Y.T., R.A.S.), Department of Neurology (C.M.B., R.A.S.), and Department of Neurosurgery (R.A.S.), Boston University School of Medicine; and Data Coordinating Center (B.M.M.), Department of Environmental Health (M.D.M.), and Department of Biostatistics (Y.T.), Boston University School of Public Health, Boston, MA.
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Nathan G. Fritts
From the CTE Center (J.M.S., A.P.B., C.M.B., N.G.F., D.H.D., Y.T., R.A.S.), Department of Anatomy and Neurobiology (J.M.S., R.A.S.), BU Alzheimer's Disease Center (A.P.B., Y.T., R.A.S.), Department of Neurology (C.M.B., R.A.S.), and Department of Neurosurgery (R.A.S.), Boston University School of Medicine; and Data Coordinating Center (B.M.M.), Department of Environmental Health (M.D.M.), and Department of Biostatistics (Y.T.), Boston University School of Public Health, Boston, MA.
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Daniel H. Daneshvar
From the CTE Center (J.M.S., A.P.B., C.M.B., N.G.F., D.H.D., Y.T., R.A.S.), Department of Anatomy and Neurobiology (J.M.S., R.A.S.), BU Alzheimer's Disease Center (A.P.B., Y.T., R.A.S.), Department of Neurology (C.M.B., R.A.S.), and Department of Neurosurgery (R.A.S.), Boston University School of Medicine; and Data Coordinating Center (B.M.M.), Department of Environmental Health (M.D.M.), and Department of Biostatistics (Y.T.), Boston University School of Public Health, Boston, MA.
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Brett M. Martin
From the CTE Center (J.M.S., A.P.B., C.M.B., N.G.F., D.H.D., Y.T., R.A.S.), Department of Anatomy and Neurobiology (J.M.S., R.A.S.), BU Alzheimer's Disease Center (A.P.B., Y.T., R.A.S.), Department of Neurology (C.M.B., R.A.S.), and Department of Neurosurgery (R.A.S.), Boston University School of Medicine; and Data Coordinating Center (B.M.M.), Department of Environmental Health (M.D.M.), and Department of Biostatistics (Y.T.), Boston University School of Public Health, Boston, MA.
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Michael D. McClean
From the CTE Center (J.M.S., A.P.B., C.M.B., N.G.F., D.H.D., Y.T., R.A.S.), Department of Anatomy and Neurobiology (J.M.S., R.A.S.), BU Alzheimer's Disease Center (A.P.B., Y.T., R.A.S.), Department of Neurology (C.M.B., R.A.S.), and Department of Neurosurgery (R.A.S.), Boston University School of Medicine; and Data Coordinating Center (B.M.M.), Department of Environmental Health (M.D.M.), and Department of Biostatistics (Y.T.), Boston University School of Public Health, Boston, MA.
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Yorghos Tripodis
From the CTE Center (J.M.S., A.P.B., C.M.B., N.G.F., D.H.D., Y.T., R.A.S.), Department of Anatomy and Neurobiology (J.M.S., R.A.S.), BU Alzheimer's Disease Center (A.P.B., Y.T., R.A.S.), Department of Neurology (C.M.B., R.A.S.), and Department of Neurosurgery (R.A.S.), Boston University School of Medicine; and Data Coordinating Center (B.M.M.), Department of Environmental Health (M.D.M.), and Department of Biostatistics (Y.T.), Boston University School of Public Health, Boston, MA.
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Robert A. Stern
From the CTE Center (J.M.S., A.P.B., C.M.B., N.G.F., D.H.D., Y.T., R.A.S.), Department of Anatomy and Neurobiology (J.M.S., R.A.S.), BU Alzheimer's Disease Center (A.P.B., Y.T., R.A.S.), Department of Neurology (C.M.B., R.A.S.), and Department of Neurosurgery (R.A.S.), Boston University School of Medicine; and Data Coordinating Center (B.M.M.), Department of Environmental Health (M.D.M.), and Department of Biostatistics (Y.T.), Boston University School of Public Health, Boston, MA.
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Citation
Age of first exposure to football and later-life cognitive impairment in former NFL players
Julie M. Stamm, Alexandra P. Bourlas, Christine M. Baugh, Nathan G. Fritts, Daniel H. Daneshvar, Brett M. Martin, Michael D. McClean, Yorghos Tripodis, Robert A. Stern
Neurology Mar 2015, 84 (11) 1114-1120; DOI: 10.1212/WNL.0000000000001358

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Abstract

Objective: To determine the relationship between exposure to repeated head impacts through tackle football prior to age 12, during a key period of brain development, and later-life executive function, memory, and estimated verbal IQ.

Methods: Forty-two former National Football League (NFL) players ages 40–69 from the Diagnosing and Evaluating Traumatic Encephalopathy using Clinical Tests (DETECT) study were matched by age and divided into 2 groups based on their age of first exposure (AFE) to tackle football: AFE <12 and AFE ≥12. Participants completed the Wisconsin Card Sort Test (WCST), Neuropsychological Assessment Battery List Learning test (NAB-LL), and Wide Range Achievement Test, 4th edition (WRAT-4) Reading subtest as part of a larger neuropsychological testing battery.

Results: Former NFL players in the AFE <12 group performed significantly worse than the AFE ≥12 group on all measures of the WCST, NAB-LL, and WRAT-4 Reading tests after controlling for total number of years of football played and age at the time of evaluation, indicating executive dysfunction, memory impairment, and lower estimated verbal IQ.

Conclusions: There is an association between participation in tackle football prior to age 12 and greater later-life cognitive impairment measured using objective neuropsychological tests. These findings suggest that incurring repeated head impacts during a critical neurodevelopmental period may increase the risk of later-life cognitive impairment. If replicated with larger samples and longitudinal designs, these findings may have implications for safety recommendations for youth sports.

GLOSSARY

%CLR=
conceptual level responses;
%E=
percent errors;
%PE=
percent perseverative errors;
%PR=
percent perseverative responses;
AFE=
age of first exposure;
CTE=
chronic traumatic encephalopathy;
DETECT=
Diagnosing and Evaluating Traumatic Encephalopathy using Clinical Tests;
DLPFC=
dorsolateral prefrontal cortex;
eVIQ=
estimated verbal IQ;
IR=
Immediate Recall;
NAB-LL=
Neuropsychological Assessment Battery List Learning test;
NFL=
National Football League;
RHI=
repeated head impacts;
WCST=
Wisconsin Card Sort Test;
WRAT-4=
Wide Range Achievement Test, 4th edition

Footnotes

  • Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Editorial, page 1068

  • Received September 5, 2014.
  • Accepted in final form November 12, 2014.
  • © 2015 American Academy of Neurology
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Letters: Rapid online correspondence

  • Author Response
    • Robert A. Stern, Boston University School of Medicinebobstern@bu.edu
    • Julie M. Stamm, Yorghos Tripodis, Boston
    Submitted April 29, 2015
  • Cognitive deficits may predate early entry into football
    • Glenn J. Larrabee, Neuropsychologist, Independent Practiceglarrabee@aol.com
    • Martin L. Rohling, Mobile, Alabama; Laurence M. Binder, Beaverton, Oregon
    Submitted March 10, 2015
  • Youth football and late-life cognitive impairment
    • Jim Andrikopoulos, Neuropsychologist, Independent Practiceneuroclinic@msn.com
    • Des Moines, Iowa
    Submitted February 26, 2015
  • Rebuttal to "Age of first exposure to football and later-life cognitive impairment in former NFL players"
    • Joseph C. Maroon, Neurosurgeon, University of Pittsburgh Medical Centermaroonjc@upmc.edu
    • Julian Bailes, Pittsburgh, PA; Michael Collins, Pittsburgh, PA; Mark Lovell, Pittsburgh, PA; Christina Mathyssek, Pittsburgh, PA
    Submitted February 23, 2015
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