I am part of a growing demographic—women who like football. My interest and enjoyment of football has grown over the years, with the help and tutelage of my husband and two sons. The National Football League (NFL) wants to keep me and my sistas in the game. We represent the only remaining opportunity for growth and advertisers understand how we spend money. But as the football season begins, I realize I have a love/hate relationship with the NFL. As much as I love football, it is becoming harder and harder to ignore the violence and the consequences of repetitive head trauma.

i_webpcard_iIn 2005, Dr. Bennet Omalu, a pathologist at the University of Pitsburgh performed an autopsy on a retired NFL player who died at the relatively young age of 50, from heart disease. Dr. Omalu noted marked changes to his brain that were similar but not identical to the neuropathological findings seen in boxers and known as Dementia Pugilistica (DP). His initial paper described the findings associated with delayed neurodegeneration induced by the “cumulative effects of repeated low-grade concussive brain injury.” He called this syndrome Chronic Traumatic Encephalopathy (CTE) (you are going to be hearing more about Dr. Omalu in the near future….. remember that name).

In the 10 years since the original paper was published, CTE has been recognized in football players, professional wrestlers, military veterans, ice hockey players and others. Although CTE has always been discussed as a consequence of extensive neurotrauma, there is now growing evidence that a major concussion is not a requirement. Instead, “repetitive subconcussive injury may play a role in CTE development.” I cannot think of anything that describes repetitive subconcussive injury better than football, especially for linemen.CTE

There is now greater acceptance of CTE as a disease by the health professions, researchers, and sports teams. This has resulted in greater public awareness and discussions at all levels that focus on reducing the risk of developing CTE by reducing the exposure to concussive and subconcussive events. Improvements to helmets may be beneficial but whether headgear can prevent or reduce the cumulative effects of repetitive head trauma is still an unknown. Organized football leagues from youth leagues to the NFL are reducing the amount of contact permitted during practice. The NFL has made significant rule changes and has emphasized their strict enforcement with penalties. Concussion management, medical surveillance, and education are all reducing the exposure to repetitive head trauma. The cases of CTE that have been reported in the literature have been in athletes that played contact sports before these updated protocols were put into effect. Only time will tell if these measures reduce the incidence of CTE.

Who will develop CTE? There are many more questions than answers. But it must be recognized that CTE is an extreme response to repetitive head trauma. Perhaps the time has come to think of a spectrum of responses to traumatic brain injury (TBI). Most NFL players will not develop CTE, but many of them may develop some symptoms which contribute to functional limitations and reduced quality of life. These consequences are not limited to football players, either. In 2010, the CDC estimated that TBIs accounted for 2.5 million emergency room visits and hospitalizations. Optometrists are committed to battling this epidemic on two fronts. First, in our offices, we are helping these patients overcome the visual deficits associated with traumatic brain injury and helping them make better decisions about when it is appropriate to return to play and return to learn or work. Second, we are providing resources and education within our communities to reduce the exposure to brain trauma.

As for my love/hate relationship with the NFL, I am encouraged by the efforts to decrease the frequency and magnitude of “repetitive subconcussive events,” but in the end I don’t believe they will be able to make substantial progress without significantly altering the game.



Omalu BI, Dekosky ST, Minster RL, Kamboh MI, Hamilton RL, Wecht CH.  Chronic traumatic encephalopathy in a National Football League player. Neurosurgery 2005;57:128-134

Bailes JB, Turner RC, Lucke-Wold BP, Patel V, Lee JM.  Chronic traumatic encephalopathy: Is it real? The relationship between neurotrauma and neurodegeneration. Clin Neurosurgery 2015;62:15-24.

Centers for Disease Control and Prevention (2014). Report to Congress on Traumatic Brain Injury in the United States:Epidemiology and Rehabilitation. National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention. Atlanta, GA.  Available at: