Retired National Football League Players Research Articles

64 Neuroimaging Evidence of Neurodegenerative Disease in Former Professional American Football Players Who “Fail” Validity Testing: A Case Series

Objective:Former professional American football players have a high relative risk for neurodegenerative diseases like chronic traumatic encephalopathy (CTE). Interpreting low cognitive test scores in this population occasionally is complicated by performance on validity testing. Neuroimaging biomarkers may help inform whether a neurodegenerative disease is present in these situations. We report three cases of retired professional American football players who completed comprehensive neuropsychological testing, but “failed” performance validity tests, and underwent multimodal neuroimaging (structural MRI, Aß-PET, and tau-PET).Participants and Methods:Three cases were identified from the Focused Neuroimaging for the Neurodegenerative Disease Chronic Traumatic Encephalopathy (FIND-CTE) study, an ongoing multimodal imaging study of retired National Football League players with complaints of progressive cognitive decline conducted at Boston University and the UCSF Memory and Aging Center. Participants were relatively young (age range 55-65), had 16 or more years of education, and two identified as Black/African American. Raw neuropsychological test scores were converted to demographically-adjusted z-scores. Testing included standalone (Test of Memory Malingering; TOMM) and embedded (reliable digit span, RDS) performance validity measures. Validity cutoffs were TOMM Trial 2 < 45 and RDS < 7. Structural MRIs were interpreted by trained neurologists. Aß-PET with Florbetapir was used to quantify cortical Aß deposition as global Centiloids (0 = mean cortical signal for a young, cognitively normal, Aß negative individual in their 20s, 100 = mean cortical signal for a patient with mild-to-moderate Alzheimer’s disease dementia). Tau-PET was performed with MK-6240 and first quantified as standardized uptake value ratio (SUVR) map. The SUVR map was then converted to a w-score map representing signal intensity relative to a sample of demographically-matched healthy controls.Results:All performed in the average range on a word reading-based estimate of premorbid intellect. Contribution of Alzheimer’s disease pathology was ruled out in each case based on Centiloids quantifications < 0. All cases scored below cutoff on TOMM Trial 2 (Case #1=43, Case #2=42, Case #3=19) and Case #3 also scored well below RDS cutoff (2). Each case had multiple cognitive scores below expectations (z < -2.0) most consistently in memory, executive function, processing speed domains. For Case #1, MRI revealed mild atrophy in dorsal fronto-parietal and medial temporal lobe (MTL) regions and mild periventricular white matter disease. Tau-PET showed MTL tau burden modestly elevated relative to controls (regional w-score=0.59, 72nd%ile). For Case #2, MRI revealed cortical atrophy, mild hippocampal atrophy, and a microhemorrhage, with no evidence of meaningful tau-PET signal. For Case #3, MRI showed cortical atrophy and severe white matter disease, and tau-PET revealed significantly elevated MTL tau burden relative to controls (w-score=1.90, 97th%ile) as well as focal high signal in the dorsal frontal lobe (overall frontal region w-score=0.64, 74th%ile).Conclusions:Low scores on performance validity tests complicate the interpretation of the severity of cognitive deficits, but do not negate the presence of true cognitive impairment or an underlying neurodegenerative disease. In the rapidly developing era of biomarkers, neuroimaging tools can supplement neuropsychological testing to help inform whether cognitive or behavioral changes are related to a neurodegenerative disease.

A - 151 Assessing the Role of Executive Function in the Memory Performances of Retired National Football League Players.

We evaluated the relationship between retired National Football League players executive functioning (EF) abilities on verbal memory performance and subprocesses. Fifty-eight participants were divided into two groups: intact executive functioning (IEF) and deficit executive functioning (DEF). Participants completed the California Verbal Learning Test, Second Edition (CVLT-II) to evaluate verbal memory performance. Additionally, the Item Specific Deficit Approach (ISDA) was applied to the CVLT-II to quantify verbal memory subprocesses (i.e., encoding, consolidation, & retrieval). Next, we determined which ISDA indices predicted long-delayed free recall (LDFR) for both groups. We then computed hierarchal regressions to determine which ISDA indices were predictive of LDFR for each group. Next, we retained significant predictors from the ISDA and correlated them with measures of executive function in both groups with and without partialling out cognitive reserve (CR). We found the IEF group outperformed the DEF group on the CVLT-II learning trials and LDFR, and demonstrated better encoding abilities. Hierarchical regression revealed that the ISDA was predictive of LDFR in both groups. The DEF group LDFR issues were only predicted by encoding problems. In contrast, LDFR deficits in the IEF were primarily driven by consolidation problems. The ISDA encoding index correlated with Trail Making Test part B and Phonemic Fluency Test. However, after partialling out the variance accounted for by CR, the associations between the encoding index and executive function were nonsignificant. Our results suggest that greater executive function results in better memory performances in retired football players. Lastly, improved executive function is related to greater CR.

“I’m Worried They Will Come Back to Haunt Me”: Examining How Retired National Football League Players Make Sense of Concussion Risks

This qualitative study examines how former National Football League (NFL) players retrospectively make sense of concussion risks post-retirement. Semi-structured interviews were conducted with retired NFL players ( N = 10) who sustained at least one official concussion during their professional career. Guided by sensemaking theory and reflexive thematic analysis, themes were generated to characterize player attitudes toward concussion risks. Themes identified include concussions represent an invisible threat, concussions create more concern than other injuries, and head injuries change player outlooks on career longevity. Player strategies to mitigate concussion risks included avoid thinking about the risks by focusing on the moment or on the financial rewards, rely on teammates to look out for each other’s health, and recognize the fine line between valor and discretion. The findings inform risk communication efforts geared toward reducing head injuries in football, as players must balance competing goals of elite performance and sustaining their football career versus prioritizing their long-term health.

Life After the Gridiron: Examining Retired National Football League Athletes’ Self-Presentation Strategies and Follower Engagement on Instagram Personal and Business Pages

As athletes enter a new chapter in their lives retiring from their sport, the challenge of upholding and enhancing personal brands arises. There has been extensive research on athlete brand building via social media; however, there have been few studies analyzing how athletes build their own brands and brand extensions postcareer, particularly former National Football League (NFL) players. Sixteen retired NFL athletes were examined using Goffman’s theory of self-presentation to determine strategies used for building personal brand extensions and obtaining follower engagement via Instagram. Through a content analysis, a total of 2,933 Instagram posts were analyzed, and the findings from this study revealed that former NFL players with fewer followers received higher engagement rates, and retired NFL players made more backstage type of posts on personal pages compared with front-stage posts. Implications, recommendations, and future research suggestions also are discussed within the paper.

Abstract EP44: Longer Retirement Time Is Associated With Lower Left Ventricular Mass In Retired National Football League Players

Background: Increased left ventricular mass (LVM), a common structural phenomenon associated with athlete’s heart, has been reported to regress following cessation from systematic high-intensity training. However, information is limited on the interplay between length of retirement and LVM in former professional field-based athletes, a segment of the population in which both hypertension and obesity, factors generally associated with increased LVM, have been reported as highly prevalent. Thus, we aimed to explore this observation in a group of former National Football League (NFL) players. Methods: This complete-case analysis included 1,348 retired NFL players (aged 53.3 ± 12.8 years, 55.5% Black) that participated in the NFL’s Player Care Foundation comprehensive health screenings between 2015 and 2021. Years since retirement from professional American-style football (YrsRetired) was calculated as year of examination minus the last self-reported year playing for the NFL. Echocardiography was used to estimate LV mass, which was then indexed to height 2.7 (LVMI). LVMI was divided into quartiles and stepwise binary logistic regression models were fitted to assess the association of YrsRetired with the lowest quartile (Q1) of LVMI, after adjusting for traditional cardiometabolic risk factors, NFL career length, and playing position group (Model 1); cardiometabolic risk factors and playing position group (Model 2); or cardiometabolic risk factors only (Model 3). Results: The prevalence of hypertension and abdominal obesity in our sample was 75.1% and 57.1%, respectively. Mean retirement length was 24.8 ± 12.7 years (range: 1.0 - 59.0 years), and mean LVMI was 40.3 ± 9.7 g/m 2.7 . Increasing YrsRetired was independently associated with higher odds for LVMI Q1 (Model 2, odds ratio [OR]: 1.03, 95% confidence interval [CI]: 1.00-1.07, p= 0.04 ; Model 3, OR: 1.03, 95% CI: 1.00-1.07, p= 0.03). When adding NFL career length to the model, the association between YrsRetired and LVMI Q1 was attenuated (Model 1, p = 0.91). Conclusions: Longer retirement is associated with lower left ventricular mass in this group of retired NFL players. These findings suggest that regression of LVM following retirement from professional sport may be common in former NFL players, despite the high prevalence of hypertension and obesity reported in this population. Further, these findings imply that elite sports participation may have a potential buffering effect against hypertension and/or obesity-induced hemodynamic changes that increase LVM, which seem to particularly occur after retirement from professional sports. This potential instance may be impacted by professional career length.

Abstract 14377: The Role of Allometric Scaling in the Association Between Professional Playing Career and Aortic Root Diameter Among Retired NFL Players

Introduction: While there is concern that participation in certain elite-level sports may increase risk for aortic dilation, clinical assessment of aortic root diameter (ARD) in professional athletes remains difficult owing to the lack of available normative data proportionate to anthropomorphic variables, which further complicates proper assessment of aortic disease during the post-professional life when risk factors may be greater. Thus, we examined the effect of allometric scaling on the association between ARD and professional football career length (NFLYrs) or playing position in retired National Football League (NFL) players. Methods: This cross-sectional study included 1,328 retired NFL players (mean age 53.1 ± 12.7 yrs; 54.6% Black) that participated in NFL Player Care Foundation health screenings. Two-dimensional echocardiogram was used to determine ARD at the sinus of Valsalva and indexed to body surface area (BSA) 0.6 (aortic root index; ARI). Multivariable-adjusted linear regression models were utilized to examine the association of playing position group and NFLYrs with ARD or ARI, after adjusting for traditional cardiometabolic risk factors. Results: The mean ARD and ARI of this study cohort were 33.0 ± 6.4 mm and 19.5 ± 3.8 mm, respectively. In regression models, NFLYrs was not associated with either ARD (B: -0.04, standard error [SE]: 0.04, p = 0.3496) or ARI (B: -0.03, SE: 0.03, p = 0.3177). Conversely, increasing ARD was associated with both Big (B: 1.12, SE: 0.53, p = 0.0340) and Big Skill (B:1.10, SE: 0.45, p = 0.0144) position groups, although this was attenuated to non-significance by allometric scaling of ARD (Big, B: -0.25, SE: 0.32, p = 0.4303; Big Skill, B: 0.22, SE: 0.26, p = 0.3978). Conclusions: NFLYrs was not associated with increasing ARD or AIH, suggesting that a longer professional football career did not potentiate larger aortic root size later in life. While football playing position was associated with increasing ARD, this association became non-significant upon indexing of ARD to BSA 0.6 , suggesting that allometric scaling may be necessary to appropriately assess aortic root diameter in these individuals. This underlines the need for further studies examining optimal allometric scaling methodologies in this population.

Abstract 11052: The Association Between Left Ventricular Mass and Coronary Artery Calcium Score in Retired National Football League Players

Introduction: Literature suggests that increased left ventricular mass (LVM) is a predictor of coronary heart disease and mortality in the general population, and that increased LVM is associated with higher CAC. However, the association between LVM and subclinical atherosclerosis as indicated by absolute CAC has not been widely explored in retired elite athletes, who may have had or still have increased LVM as a result of exercise adaptation. Thus, we sought to investigate this association in a cohort of retired National Football League (NFL) players. Methods: This cross-sectional study included 632 retired NFL players aged 40 and older (mean age 56.4 ± 9.7 yrs; 51.3% Black) that participated in NFL Player Care Foundation health screenings. Two-dimensional echocardiogram was used to determine LVM according to American Society of Echocardiology guidelines and indexed to height to obtain left ventricular mass index (LVMI, g/m 2.7 ). LVH was considered as LVMI &gt 49.2 g/m 2.7 . Multi-variable logistic regression models were utilized to determine the association of LVM with the highest quintile of CAC (CAC = 264-6239) after adjusting for traditional cardiometabolic risk factors. Results: The mean LVM of study participants was 220.8 ± 56.6 g and the prevalence of LVH 16.9%. LVM was highest in the 2 nd quintile of CAC, with LVM in the highest quintile of CAC significantly lower than that of the first and second quintiles and not significantly different from that of the 3 rd or 4 th quintiles. Multi-variable logistic regression models revealed that increasing LVM was associated with decreased odds for the highest quintile of CAC (odds ratio [OR]: 0.99, 95% confidence interval [CI] 0.99 - 1.00, p = 0.0486), with no such association for LVH (OR: 0.72, 95% CI 0.37-1.41, p = 0.3429). Conclusion: Odds for increased atherosclerotic cardiovascular disease risk, as indicated by the highest quintile of CAC, are decreased by augmented LVM within physiological range in this cohort of retired NFL players, possibly reflective of a potential protective effect of high lifetime exercise dose. These results suggest that there may be lingering or carryover effect of early life cardiovascular fitness, even in middle-aged retired athletes.

Age of First Exposure to Contact and Collision Sports and Later in Life Brain Health: A Narrative Review.

A controversial theory proposes that playing tackle football before the age of 12 causes later in life brain health problems. This theory arose from a small study of 42 retired National Football League (NFL) players, which reported that those who started playing tackle football at a younger age performed worse on selected neuropsychological tests and a word reading test. The authors concluded that these differences were likely due to greater exposure to repetitive neurotrauma during a developmentally sensitive maturational period in their lives. Several subsequent studies of current high school and collegiate contact/collision sports athletes, and former high school, collegiate, and professional tackle football players have not replicated these findings. This narrative review aims to (i) discuss the fundamental concepts, issues, and controversies surrounding existing research on age of first exposure (AFE) to contact/collision sport, and (ii) provide a balanced interpretation, including risk of bias assessment findings, of this body of evidence. Among 21 studies, 11 studies examined former athletes, 8 studies examined current athletes, and 2 studies examined both former and current athletes. Although the literature on whether younger AFE to tackle football is associated with later in life cognitive, neurobehavioral, or mental health problems in former NFL players is mixed, the largest study of retired NFL players (N = 3,506) suggested there was not a significant association between earlier AFE to organized tackle football and worse subjectively experienced cognitive functioning, depression, or anxiety. Furthermore, no published studies of current athletes show a significant association between playing tackle football (or other contact/collision sports) before the age of 12 and cognitive, neurobehavioral, or mental health problems. It is important to note that all studies were judged to be at high overall risk of bias, indicating that more methodologically rigorous research is needed to understand whether there is an association between AFE to contact/collision sports and later in life brain health. The accumulated research to date suggests that earlier AFE to contact/collision sports is not associated with worse cognitive functioning or mental health in (i) current high school athletes, (ii) current collegiate athletes, or (iii) middle-aged men who played high school football. The literature on former NFL players is mixed and does not, at present, clearly support the theory that exposure to tackle football before age 12 is associated with later in life cognitive impairment or mental health problems.

Career Length And Left Ventricular Diastolic Function Among Retired National Football League Players

Career Length And Left Ventricular Diastolic Function Among Retired National Football League Players

Distribution And Correlates Of Impaired Renal Function In Retired National Football League Players

Distribution And Correlates Of Impaired Renal Function In Retired National Football League Players

Abstract 17373: The Association of Professional American-Style Football Career Length With Left Ventricular Geometry in Retired National Football League Players

Introduction: There is widespread interest in the long-term cardiovascular (CV) implications of professional football. Studies have suggested that retired National Football League (NFL) players have a high prevalence of hypertension, which may increase risk for left ventricular hypertrophy (LVH). However, it is unknown if football-specific factors, such as professional football career length (NFLYrs), are associated with long-term CV outcomes, including changes in left ventricle (LV) geometry. Thus, we examined the association of NFLYrs with LV geometry patterns in a retired NFL player cohort. Methods: We analyzed data on 1349 retired NFL players (aged 53.1 ± 12.8 years, 55.1% African-American) that underwent comprehensive health screening with the NFL Player Care Foundation. Echocardiography was used to estimate LV mass, which was then indexed to height 2.7 . Relative wall thickness was computed to classify LV geometry patterns into normal, concentric remodeling (CR), eccentric hypertrophy (EH), and concentric hypertrophy (CH). Three binary logistic regression models (Model 1: CR; Model 2: EH; Model 3: CH), using normal geometry as reference, were fitted to assess the association of NFLYrs with each LV geometry pattern, adjusting for traditional cardiometabolic risk factors. Results: Increasing NFLYrs was independently associated with CR (odds ratio [OR]: 1.48, 95% confidence interval [CI] 1.03 – 2.11, p = 0.0334), while no associations were observed with EH (OR: 0.49, 95% CI 0.22 – 1.09, p = 0.0801) or CH (OR: 1.04, 95% CI 0.61 – 1.77, p 0.8927). Mean arterial pressure was independently associated with increased odds of CR (OR: 1.03, 95% CI 1.01 – 1.05, p – 0.0017), EH (OR: 1.06, 95% CI 1.02 – 1.09, p = 0.0013), and CH (OR: 1.06, 95% CI 1.04 -1.09, p < 0.0001). Conclusion: NFL career length is not associated with increased odds for EH and CH later in life. In contrast, increased NFLYrs is associated with CR, likely an adaptive response to intense athletic training. Cardiovascular risk factors such as high blood pressure in the retirement period appear to be more important for long-term LVH risk in NFL athletes, underscoring the need for preventive initiatives aimed at decreasing risk for future CV outcomes in athletes transitioning out of professional sports.

Abstract 17065: Performance of Cardiovascular Disease Risk Scores to Identify Coronary Artery Calcium Burden in Retired National Football League Players

Introduction: Coronary artery calcium (CAC) is a robust predictor of coronary events in asymptomatic individuals with latent atherosclerotic cardiovascular disease (CVD). While evidence suggests CAC scoring may augment traditional CVD risk scores in clinical decision making, evidence is limited on the compared ability of CVD risk scores to identify the degree of coronary atherosclerosis as quantified by absolute CAC, particularly in former elite athlete populations. We investigated this in a cohort of retired National Football League (NFL) players. Methods: We analyzed data on 752 retired NFL players (aged 55.2 ± 9.0 years, 53.7% African-American] that underwent health screening and CAC scoring with the NFL Player Care Foundation. Three 10-year CVD risk scores were compared: Framingham Coronary Heart Disease (FCHD), Framingham CVD (FCVD), and Atherosclerotic CVD Risk Pooled Cohort Equations (PCE). Receiver operating characteristic curves were fitted in 3 models: FCHD (Model 1), FCVD (Model 2), and PCE (Model 3, used as reference based on 2013 AHA guidelines). Contrast analyses identified the model with highest discriminative ability (c statistic) versus CAC = 0 for each CAC score category: >0 and <100, 100-400, and >400. Results: Compared to PCE , FCVD exhibited the highest discriminative ability for CAC > 0 and < 100 ( c statistic 0.7071 vs 0.6706, p<0.0001), while FCHD had the lowest for both CAC 100-400 ( c statistic 0.7198 vs 0.7664, p=0.0165) and CAC >400 ( c statistic 0.7728 vs 0.8460, p<0.0001). No additional differences were identified (Figure 1). Conclusion: Traditional CVD risk scores differ in performance to predict absolute CAC among retired NFL players, underscoring a need for refinement of coronary event risk prediction models to enhance the ability of such models to identify, specifically, low CAC, as even low CAC burden confers increased risk compared to CAC absence. This may include accounting for elite athlete-specific characteristics.

Mild Cognitive Impairment in Retired Professional Football Players With a History of Mild Traumatic Brain Injury: A Pilot Investigation

Traumatic brain injury (TBI) is a known risk factor for neurodegenerative dementias such as Alzheimer disease (AD); however, the potential risk of mild cases of TBI, such as concussions, remains unclear. To explore whether a small sample of retired professional athletes with a diagnosis of mild cognitive impairment (MCI)-the prodromal stage of AD-and a history of multiple mild TBIs exhibit greater neuropsychological impairment than age-matched nonathletes with MCI and no history of TBI. Ten retired National Football League players diagnosed with MCI and reporting multiple mild TBIs, and 10 nonathletes, also diagnosed with MCI but with no history of TBI, completed a standard neurologic examination and neuropsychological testing. Independent samples t tests were conducted to examine differences in neuropsychological performance between the two groups. The retired athletes with a history of mild TBI obtained generally similar scores to the nonathlete controls on measures of verbal learning and memory, verbal fluency, and processing speed. However, the retired athletes scored lower than the controls on tests of confrontation naming and speeded visual attention. Retired athletes with MCI and a history of mild TBI demonstrated similar neuropsychological profiles as nonathlete controls despite lower scores on measures of confrontation naming and speeded visual attention. These findings suggest that a history of multiple mild TBIs does not significantly alter the overall neuropsychological profile of individuals with MCI; confirmation of this will require longitudinal research with larger sample sizes.

History of opioid use as a risk factor for current use and mental health consequences among retired National Football League athletes: A 9-year follow-up investigation

BackgroundMany retired National Football League (NFL) athletes manage pain with opioids during their playing careers and in retirement, though the longitudinal association between opioid use and health outcomes pertinent to an NFL career are not yet known. This study aimed to assess the relationship between opioid use in 2010 and current use, depressive symptoms, and health related quality of life (HRQoL) among NFL retirees. MethodsFormer NFL athletes from the Retired NFL Players Association initially recruited in 2010 for a study examining risk factors of opioid use and misuse were re-contacted (N = 89) from 2018 to 2019 and administered measures of pain, opioid use, depressive symptoms, and HRQoL. Binomial regression examined the association between 2010 opioid use with current use, moderate-severe depressive symptoms, and average and above HRQoL (physical and mental) while controlling for covariates. ResultsNearly 50 % of retirees using opioids in 2010 currently used. Compared to non-users, retirees who used opioids in 2010 had greater odds of current use (AOR: 3.71, 95 % CI: 1.02−13.56, p = 0.046) and experiencing moderate-severe depressive symptoms (AOR: 5.93, 95 % CI: 1.15−30.54, p = 0.033). Retirees reporting use in 2010 also evidenced lower odds of reporting average or above mental HRQoL (AOR: 0.13, 95 % CI: 0.03−0.67, p = 0.015) compared to non-users. ConclusionsThis study showed that among NFL retirees, early retirement opioid use predicted current use and deleterious effects on mental health, including moderate-severe depressive symptoms approximately nine years later. This investigation further supports the importance of early intervention of pain and opioid use among this population.

Negative health consequences of pain catastrophizing among retired National Football League athletes.

This study examined the association between pain catastrophizing with pain interference, depressive symptoms, and health-related quality of life (HRQoL) among National Football League (NFL) retirees. Former NFL athletes from the Retired NFL Players Association (N = 90) were recruited from 2018 to 2019 via telephone and were administered measures of pain, substance use, depressive symptoms, and HRQoL. Multiple linear and binomial regression analyses examined the association of pain catastrophizing with pain interference, depressive symptoms, and HRQoL while controlling for covariates (i.e., pain intensity, concussions, opioid use, binge alcohol use, years since NFL retirement, and marital status). Many retired NFL athletes reported moderate-severe depressive symptoms as well as poorer perceived physical health compared with general medical patients. Greater pain catastrophizing was associated with more severe pain interference, greater odds of reporting moderate-severe depressive symptoms, and lower odds of reporting average and above physical and mental HRQoL after adjusting for relevant covariates. Concussions were not associated with any of the study outcomes. Given the findings from this study, health care professionals should monitor symptoms of catastrophizing among current and retired NFL athletes. Assessment and requisite treatment of pain catastrophizing may assist these elite athletes in reducing depressive symptoms, while improving pain interference and HRQoL in this population. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Depression Following Concussion in Retired Professional Football Players

Clinical Question: In retired National Football League (NFL) players, what is the prevalence of depression after sustaining concussions? Clinical Bottom Line: There is emerging evidence to support the clinical question that retired NFL players with a history of concussion may be diagnosed with depression.

Self-Reported Head Trauma Predicts Poor Dual Task Gait in Retired National Football League Players.

ObjectiveSymptomatic head trauma associated with American‐style football (ASF) has been linked to brain pathology, along with physical and mental distress in later life. However, the longer‐term effects of such trauma on objective metrics of cognitive–motor function remain poorly understood. We hypothesized that ASF‐related symptomatic head trauma would predict worse gait performance, particularly during dual task conditions (ie, walking while performing an additional cognitive task), in later life.MethodsSixty‐six retired professional ASF players aged 29 to 75 years completed a health and wellness questionnaire. They also completed a validated smartphone‐based assessment in their own homes, during which gait was monitored while they walked normally and while they performed a verbalized serial‐subtraction cognitive task.ResultsParticipants who reported more symptomatic head trauma, defined as the total number of impacts to the head or neck followed by concussion‐related symptoms, exhibited greater dual task cost (ie, percentage increase) to stride time variability (ie, the coefficient of variation of mean stride time). Those who reported ≥1 hit followed by loss of consciousness, compared to those who did not, also exhibited greater dual task costs to this metric. Relationships between reported trauma and dual task costs were independent of age, body mass index, National Football League career duration, and history of musculoskeletal surgery. Symptomatic head trauma was not correlated with average stride times in either walking condition.InterpretationRemote, smartphone‐based assessments of dual task walking may be utilized to capture meaningful data sensitive to the long‐term impact of symptomatic head trauma in former professional ASF players and other contact sport athletes. ANN NEUROL 2020;87:75–83

Retired National Football League Players are Not at Greater Risk for Suicide.

ObjectiveSome researchers have claimed that former National Football League (NFL) players are at increased risk for suicide as a clinical feature of chronic traumatic encephalopathy (CTE). This review examines the literature on risk for suicide in former professional football players, and the association between suicide and CTE.MethodA narrative review of the literature published between 1928 and 2018.ResultsBetween 1928 and 2009, suicide was not considered to be a clinical feature of CTE in the literature. The best available evidence from epidemiological studies suggests that former NFL football players are at lesser risk for suicide, not greater risk, compared to men in the general population. However, surveys have revealed that a substantial minority of former NFL players have depression and other mental health problems, chronic pain and opioid use is relatively common, and those with depression and chronic pain also have greater life stress and financial difficulties. That minority would be at increased risk for suicidal thoughts and behaviors.ConclusionsResearchers and clinicians are encouraged to be cautious and circumspect when considering the clinical presentation of former athletes, and to not assume that depression and suicidality are caused by specific types of neuropathology. This represents a reductionistic and Procrustean view. Some former football players have mental health problems, but it should not be assumed uncritically that the underlying cause is an inexorably progressive neurodegenerative disease. Providing evidence-informed and evidence-supported treatments for depression and suicidality might reduce suffering and improve their functioning.

Osteoarthritis Prevalence in Retired National Football League Players With a History of Ankle Injuries and Surgery.

Ankle injuries are common at all levels of American football, and retired National Football League (NFL) players have a high prevalence of osteoarthritis (OA), but little is known about how ankle injuries influence OA prevalence and daily activities in this population or how surgical interventions for such injuries alter the risk of OA. To examine (1) the association of ankle-injury history with OA prevalence, (2) the association of surgical intervention after ankle injury with OA prevalence, and (3) the relationships among ankle injuries, reported OA, and daily activities in retired NFL players. Case-control study. Survey. Data from the Retired NFL Players General Health Survey. We created a 7-category main exposure variable that differentiated respondents by football-related ankle injury and surgical intervention. Multivariable binomial regression models were used to estimate prevalence ratios and 95% confidence intervals. Among those reporting OA, we examined the distribution of responses regarding whether OA affected daily activities. Among the 2446 respondents, 920 participants experienced OA in any joint during their lifetime. Compared with those reporting no ankle injuries, the prevalence of OA was higher among those with a history of ankle injury. Also, the prevalence of OA was higher among those who had undergone surgery versus those who had not. The number of retired NFL players who reported that OA often affected their daily activities increased with the number of ankle injuries. Among former NFL players, a history of ankle injury increased the prevalence of OA. More ankle injuries increased the probability that OA negatively affected daily activities. Future prospective research is needed to better determine the influence of surgical intervention at the ankle or foot on OA.

No Linear Association Between Number of Concussions or Years Played and Cognitive Outcomes in Retired NFL Players.

The aim of the current study is to examine whether concussion history and years played are linearly associated with cognitive outcomes in retired National Football League (NFL) players. Thirty-five retired NFL players over the age of 50 who had sustained at least one concussion completed a clinical interview and brief neuropsychological battery. Correlational analyses were conducted between exposure variables [number of total concussions, concussions with loss of consciousness (LOC), and years played] and cognitive performance as characterized by cognitive composite scores based on performance on neuropsychological measures (attention/processing speed, language, memory, and overall composite scores). Correlational analyses corrected for multiple comparisons did not reveal any statistically significant correlations between exposure variables and cognitive outcomes. We did not find a significant linear association between cognitive outcomes and either number of total concussions, concussions with LOC, or years played in the NFL. These findings do not support a dose-response relationship between sports-related exposure to head impacts and cognitive outcomes later in life. Rather, the findings suggest that cognitive difficulties experienced by some retired players later in life are not directly linearly associated with quantified exposure to head impacts sustained throughout a football career, but related to factors or combinations of factors that have yet to be elucidated.