If professional athletes are meant to be real-life superheroes, Miami Dolphins star Tua Tagovailoa looked remarkably mortal on September 12. With his team down 31-10 in the third quarter against the Buffalo Bills, the quarterback spotted a gap at the line of scrimmage and decided to scramble for a first down. When he encountered Bills' defender Damar Hamlin, Tagovailoa lowered his head and ran straight into him. Tagovailoa stayed down injured after the play. He had suffered the third concussion of his NFL career, on top of the one he was diagnosed with during his time in the collegiate ranks.
As many as one in three former NFL players believe they have a chronic brain condition linked to repeated trauma to the head, recent research from Harvard has shown. It's a shocking statistic and, currently, the condition can only be definitively diagnosed through a postmortem examination. However, a simple blood test could one day help identify these invisible head injuries, which even a CT scan can't spot, and prevent a player from returning to the game before their brain has healed.
On paper, Tagovailoa did what a quarterback is supposed to do: sacrifice his body for the good of the team. But, in 2024, that mantra of self-sacrifice rings hollow, particularly when it comes to blows to the head. This isn't an NFL-specific issue, either. The NHL, for example, has tried to weed out checks from behind and hits to the head, even as fighting persists. In the world of soccer, which is traditionally viewed as a less physical sport, concussion substitutes now allow managers to remove a player with a suspected head injury from a match with fewer drawbacks. And heading the ball is being phased out at the youth level.
But even with those efforts, traumatic brain injuries including concussions are common both inside and outside the sporting world, accounting for an estimated 4.8 million emergency room visits in the U.S. every year. Without appropriate treatment and support, concussion—especially following repeated blows to the head—can lead to long-term consequences, including memory problems, changes in personality, sleep disorders, psychological issues and an increased risk of neurodegenerative diseases like dementia.
That's true even for those who aren't playing at the highest level. Patrick Risha's football career took him from the youth ranks to Dartmouth University, but the game he loved also took its toll.
"We lost Patrick in 2014 to suicide," Karen Zegel, Patrick's mother and the president of the Patrick Risha CTE Awareness Foundation, told Newsweek. "And at the time we didn't know what we were dealing with. He had evidence of depression, ADHD, addiction issues, anxiety, sleep problems. He had a lot of issues, but we had no clue that he was dealing with the consequences of playing a sport. And it wasn't until somebody suggested that we should get his brain tested for that, that we discovered about CTE."
The Mayo Clinic defines CTE, or chronic traumatic encephalopathy, as "a brain disorder likely caused by repeated head injuries. It causes the death of nerve cells in the brain, known as degeneration.... The only way to definitively diagnose CTE is after death during an autopsy of the brain."
Though Risha never played beyond the college ranks, head injuries don't look at your resume.
Tony Dorsett, one of the NFL's greatest running backs, has previously spoken about memory issues and emotional outbursts tied to potential CTE. During the summer of 2011, three NHL enforcers, Derek Boogaard, Wade Belak and Rick Rypien, all died within a matter of months; it turned out they were all suffering from CTE. Scott Vermillion, a soccer player who died in 2020, was also diagnosed with it after his death. While it's easy to understand a twisted ankle or a broken arm, traumatic brain injuries are often hard to spot.
"Patrick never had a diagnosed concussion," Zegel continued. "Patrick never complained about football or concussions or anything to do with it. But here he ended up with a disease that so destroyed his brain that he couldn't live anymore, he couldn't take the pain anymore."
"We have three frontiers left as far as I'm concerned," Doug Zegel, Patrick's stepfather, told Newsweek. "And that's deep oceans, deep space and the human brain."
Biomarkers Identify Brain Trauma
That could, however, be about to change. In February 2018, the U.S. Food and Drug Administration approved the marketing of the nation's first-ever blood test to evaluate traumatic brain injury. An updated, handheld version of the test was released this past April by Abbott, which can even be used at a patient's bedside.
While the test currently must be used in a health care setting by trained medical staff, Abbott envisions its application "wherever it's needed, whether that's in the lab, at the scenes of car crashes and collisions or on the sidelines of sports events," a company spokesperson said.
The test, which uses whole blood rather than plasma, can be much more easily administered even without access to a laboratory.
Raquel Gardner, a neurologist and director of clinical research at Sheba Medical Center in Israel, told Newsweek how it works. "The technology is based on two proteins that are measured in the blood and are indicative of brain injury or injury to the central nervous system," Gardner said. "One of these markers is related to neuronal injury and the other is a marker of glial injury, which are the support cells of the brain."
Specifically, these proteins are known as ubiquitin C-terminal hydrolase L1 and glial fibrillary acidic protein.
"When someone has a traumatic brain injury that results in bleeding in the brain, these two proteins become quite elevated above what is actually expected in the blood," Gardner said. "And each one has a different trajectory over time. Scientists have put these two biomarkers together in a single test which allows you to evaluate someone for brain trauma within minutes of their injury and 24 hours later."
To date, the approved blood test has been used only in emergency room settings, to assess whether patients need a CT scan following a blow to the head, but the blood test is on the NFL's radar.
"We obviously monitor all the developments in that area really, really carefully because we're constantly looking at how we can get better at potentially identifying, diagnosing and managing concussions," Dr. Allen Sills, the NFL's chief medical officer, told Newsweek. "So, it's part of our work to make sure we keep very close watch on all of the research and the data."
However, Sills added, there is some way to go before biomarker-based tests are used to rule out concussion. "Some of the earliest work and the first biomarkers to be sort of commercially available are really not biomarkers for concussions. That's a little bit of a misnomer. They're actually biomarkers that are reflective of bleeding in the brain," he said.
"And that is, of course, a really important advance when you think about a public health condition like brain trauma. [But] that's not super relevant in sports concussion because very, very, very few—I mean a fraction of a percent of sporting concussions—will have any bleeding in the brain."
"If someone comes in and they're completely unconscious, they're not going to need this test, they're going to go straight for the CT scan," Gardner said. "But if it's unclear and you give people this test and it's below the threshold for brain trauma, then you can be 99 percent confident that they don't have any bleeding in the brain.
"So the test spares people from getting head CT scans, which involve exposure to radiation, are costly and often involve spending more time in the emergency department.
"As a neurologist, I'm really excited about the potential of this test to help us understand those 'invisible traumatic brain injuries,'" she added.
However, it is still an area of active research. "We need to better understand what exactly are the normal levels of these blood biomarkers in the general population," Gardner said. "And then the next issue is to understand exactly what threshold means that you have a clinically significant brain injury."
Frederick Korley, a professor of emergency medicine at the University of Michigan, said that it was also unclear whether the levels of these proteins would be high enough to measure in patients with only small amounts of brain cell death.
"This is an important issue that needs to be studied," Korley told Newsweek.
If these hurdles are to be overcome, how might this technology be used to support players?
"In the NFL, concussions are rarely missed because each game has at least three physician neurotrauma consultants and two athletic trainer spotters that are on the lookout for injuries," Korley said. "[But,] concussions are definitely missed in high-risk sports where there is no active monitoring."
A Return-to-Play Game Changer
Dr. Javier Cárdenas, director of the WVU Rockefeller Neuroscience Institute Concussion and Brain Injury Center, told Newsweek that, regardless of the specific sport, the overall game changer from his perspective would be the ability to use the blood test to assess concussion recovery, rather than the initial diagnosis.
"I would argue that removing an athlete with a suspected concussion is relatively easy if you've done this quite a bit," said Cárdenas, who is also the vice chairman of the NFL Head, Neck and Spine Committee. "What's really hard is knowing when the brain has healed and when an athlete is genuinely ready to return to a sport in which they can hit their heads."
While return-to-play protocols vary from league to league, they generally involve a player demonstrating a lack of symptoms and passing cognitive tests while resuming various levels of physical activity. But, even within that process, things aren't always cut-and-dried.
"The problem is, we know that most of these tests lose their sensitivity to concussion the further and further you get from the injury, in which case the certainty for brain healing is less," Cárdenas said. "And so, as much as we try, it is really hard to absolutely determine when somebody's brain is healed such that they can go back to play. And again, from my perspective, that's where the biomarkers have their greatest potential."
Sills agreed with Cárdenas about the potential for these biomarker-based tests in return-to-play scenarios, assuming they meet the appropriate level of scrutiny.
"If biomarkers improve with their sensitivity and specificity, we will first see them used in the return to participation process," Sills said. "So that we can track the time course of injury and correlate the biomarkers with symptoms and the neuropsychological testing and the clinical testing that we currently do to help confirm that the brain is indeed recovered."
"I look at [the NFL's concussion protocol] as a very living and breathing document," Sills added. "And one that we want to constantly reflect the state of the science."
Other Head Protection for Players
Biomarker-based tests aren't the only area where progress can be made. Policies can and have changed. Many leagues have tried to crack down on hits to the head, which was one of the reasons why the NFL adjusted kickoffs ahead of the 2024 season.
Safety can also be addressed through equipment, with one such change arriving during the most recent NFL offseason. Players are now allowed to wear Guardian Caps, a soft-shelled outer layer added to helmets, during competitive games. They were previously mandated for preseason practices as well as regular and postseason practices involving contact for players in positions that have the most collisions.
While the presence of additional headgear is still a rarity on Sundays, with some players voicing concerns about the extra weight and debate about their effectiveness still ongoing, other athletes have added the cap to their game-day repertoire.
"I don't really care how it looks as long as it keeps you safe," Tennessee Titans tight end Josh Whyle, who previously suffered two concussions, told his team's official website. "It's a decision as I was coming back [from the concussion]. I got a new helmet as well, and I just think the extra protection, if they are allowing it...it's great. Why not?"
Indianapolis Colts tight end Kylen Granson, who suffered a concussion in 2023, was more blunt. "At one point people thought seat belts were f****** stupid," he said. "I'm going to get married this coming year. I want to be able to remember
our first dance 30 years from now. I want to be able to remember my first kid's steps, I want to be able to be there at their first day of school."
Not everyone agrees. When asked at an October 21 press conference if he'd wear a Guardian Cap going forward, Tagovailoa said: "Nope.... There's just risk in any and everything, and I'm willing to play the odds."
During the 2024 preseason, the NFL reported the fewest concussions since tracking began in 2015. According to Sills, the Guardian Cap, in addition to improving helmets and an overall culture change about head contact, helped shape that statistic.
And during the 2023 campaign, 44 percent of NFL concussions had an element of self-reporting while overall concussion numbers decreased.
"I've been a sports physician for almost three decades," Sills added. "I can tell you that we did not see that degree of self-reporting, you know, 10 or 15 years ago. People tended to try to minimize the injury or maybe play through it and not admit that they might be injured. So, that's a substantial change."
And while there are instances that could prompt cynicism—some felt, for example, that Buffalo Bills quarterback Josh Allen's rapid return to an October 6 game against the Houston Texans warranted a further investigation—Sills is confident in the NFL's numbers.
"First of all, we have submitted our data for publication because we want to get it in the peer-reviewed literature," he explained. "So, it's under review right now. That's an important step for us. But we're going to analyze our data and continue to look for ways to improve. We're fond of saying there's no finish line for health and safety. We can always get better. We can always improve. We can always be safer. We will continue to look at the data very carefully, and we'll look at where advances have been made but also look for where there are opportunities to make further advancements."
The idea of overall knowledge and a culture shift connects with the Patrick Risha CTE Awareness Foundation's efforts.
"For us, safer sports would begin with an informed public," Doug Zegel said. "And maybe we can rate these sports by the level of impact that they incorporate.... We rate our movies, but we don't rate our sports.
"Obviously, in the perfect world, we'd ban every sport that has repetitive impacts because, whether you're hitting shoulder-to-shoulder or head-to-head, your brain is being affected. But at least if parents and people understood the danger, they could make informed decisions and choose to participate or not. I don't think we can tell anybody what to do anymore, but if we give them some good information, maybe they'll make an intelligent decision."
Whether it involves players in youth ranks or the professional level, having a way to confirm what's going on inside of someone's skull could be a game changer, with biomarker-based testing making for better decisions during the return-to-play process.
"I'm really pleased to see that people are talking about head contact, that they're focusing on it, and we're looking at ways to minimize it because we all know there are tremendous benefits from playing in sports, particularly team sports," Sills said.
"As a neurosurgeon, I've spent my entire career treating patients that have brain and spinal trauma, so anything we can do to make sports safer, to me, is a great advance. I'm also a parent of several athletes who played in college, and I have nine grandchildren who play sports. Sports safety to me is not just my job, it's a family matter and a matter of, I think, community."
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