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All of the players were able to complete the test with relative accuracy, but the brain activity of the four players who took a lot of middling hits—but suffered no concussions—changed dramatically. When each one took the harder version of the test, there was an unmistakable decline in activity in an area of the brain just behind the forehead called the dorsolateral prefrontal cortex, which is critical to visual memory. "It's like a horse race," says Talavage. "When the brain starts a task, it starts all the horses running, and one wins, or gets the task done. But when the brain is already taxed, it prevents some of those horses from starting. There are fewer resources available."
Talavage has seen an interesting parallel in an unrelated study that compares gifted children with reading-impaired and average children. The gifted kids show relatively low brain activity on a reading test, presumably because they aren't challenged and need not summon all their mental horsepower. The average children start all the horses. But the reading-impaired subjects, like the gifted children, keep some of the starting gates closed—not because the task is too easy but because it is too difficult. A single week of 150 hits turned the four "functionally impaired" Jefferson High players, as the Purdue team calls them, into equivalents of the reading-impaired children, except that the damage was to visual memory.
Yet every method of sideline diagnosis for concussions relies on self-reported symptoms like headaches or dizziness, in addition to tests of verbal—not visual—memory. The NFL, for example, now mandates that a concussed player is done for the day if, after a hit, he can't carry on a coherent conversation or remember the last play or his gap assignment. The four functionally impaired Bronchos, however, showed absolutely nothing that would be categorized as a symptom. "You wouldn't even know to examine them," says Larry Leverenz, an athletic trainer and Purdue clinical professor of health and kinesiology who is on the study team. "There's nothing until you give them an fMRI or test the visual memory."
Even in the gladiator culture of football, the growing awareness of brain injury has transformed the act of hiding a concussion from one signifying bravery to one of stupidity. The functionally impaired four didn't hide symptoms; they never knew they had any.
BEYOND THE FACT that the best predictor of impaired visual memory was not concussions but the number of hits absorbed in the previous week, one other bit of data jumped out at the Purdue researchers. While the players who were diagnosed with concussions tended to take heavy hits on the side of the helmet, the functionally impaired four tended to get hit on the front, essentially in the upper forehead, which houses the dorsolateral prefrontal cortex—where linemen get hit, play in and play out. It wasn't the rare, excessively violent collision between the wide receiver and the free safety, the Patriot missile intercepting the Scud, that mattered most, but rather the milder, more frequent kind of hits that replicated two adolescent rams knocking heads.
Consider this: Concussions as we know them involve a hit that rattles a part of the brain involved in language processing or motor skills. Hits to the forehead that might be every bit as damaging hide their nefarious effects in the frontal lobe, a part of the brain primarily involved in visual memory, planning and cognition, rather than motor or sensory function, and thus not taxed by sideline concussion exams. Indeed, it's possible that all along, while brain trauma questions have focused on concussions, the real damage is being inflicted by minor impacts that chip away at the brain. A 2009 study by researchers including Ann McKee, the Boston University neurologist who has autopsied the damaged brains of deceased former NFL players, noted that long-term brain deterioration did not strictly correspond to the history of concussions.
Randall Benson, a neurologist at Wayne State in Detroit who has studied former NFL players suffering from cognitive impairment and depression, says that some of them never suffered a concussion. Benson thinks the Purdue researchers may have taken a real-time snapshot of the early stages of the corrosive creep that wears away the frontal lobe, a part of the brain involved in navigating social situations. Too much erosion and victims reach a breaking point—like former Steelers offensive lineman Terry Long, who died in 2005 from drinking antifreeze. "It's an insidious progression," Benson says, "and it's not obvious when you talk to [players]." Benson has seen MRIs that show the brain drifting in the head with a movement as routine as a twisting of the neck. "It would defy the laws of physics if the brain didn't have a shearing injury when you stick your face into a 275-pound defensive lineman," he says.
But what if it doesn't take a 275-pound lineman? What if it takes only a 190-pound Brandon Stumph, the likes of whom many of the 1.1 million high school football players will encounter regularly on the field? Or what if it doesn't take even that? What if it just takes a one-pound soccer ball? In a 2003 study from the Florida Institute of Technology, subjects were briefly shown a design and directed to redraw it. Only one of 12 non-soccer-playing control subjects scored below the normal range, compared with seven of 21 soccer players who had a history of frequent headers. That cohort also scored worse on an IQ test than the control group, and lower than players who did not head the ball as frequently.
The mounting evidence suggests that some people—perhaps a lot—simply cannot play these games without being damaged, concussion or no concussion. "You can break something by hitting it hard once," says Katie Morigaki, a Purdue graduate assistant athletic trainer who worked on the study, "or you can break it by hitting it softer many times."
AND NOW THE GOOD NEWS. "There are issues we can address without changing football or racking up costs," says Nauman. If it's simply the number of hits that predict whether a player will suffer brain damage, then, like pitch counts, that can be managed. Instead of full-contact practice on Tuesdays and Wednesdays, high schools could take a cue from the pros. "If a school can't afford all this stuff"—like fMRI, which they invariably can't—"if they hit one fewer day a week, they're probably in better shape," Nauman says. Even simpler would be a cultural shift from the head-butt back to the high-five. The Purdue team found the Jefferson players' celebratory helmet-knocks registered 80 to 100 Gs near the frontal lobe.