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Relating American Football Age of First Exposure to Patient-Reported Outcomes and Medical Diagnoses Among Former National Football League Players: An NFL-LONG study

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Abstract

Background

The age of first exposure (AFE) to American football participation is a growing concern for late-life function. Mixed evidence exists surrounding AFE and may be attributed to varied methods employed across studies.

Objective

To examine the associations between AFE to American football participation with measures of cognitive, behavioral, and physical function and brain-related medical diagnoses across age categories among former National Football League players.

Methods

We conducted a cross-sectional survey of 1784 former players (age: 52.3 ± 16.3 years, AFE: 11.3 ± 2.9 years, years of football: 17.5 ± 4.5 years, 86.9% ≥ one lifetime concussion). Players completed a general health questionnaire recording demographics, football playing history (including AFE), and diagnoses (anxiety, depression, any form of dementia, mild cognitive impairment). Players completed Patient-Reported Outcomes Measurement Information System (PROMIS) measures assessing domains of cognitive and physical function, anxiety, depression, sleep disturbance, pain interference, and emotional-behavioral dyscontrol. Multivariable linear and binomial regression models were used to examine the associations of AFE and age with PROMIS outcomes and diagnoses, respectively.

Results

No significant AFE by age interactions were detected for PROMIS outcomes (p ≥ 0.066) or diagnoses (p ≥ 0.147). Younger AFE associated with higher PROMIS scores of anxiety (B = − 0.22, p = 0.016), depression (B = − 0.22, p = 0.010), sleep disturbances (B = − 0.16, p = 0.007), pain interference (B = − 0.19, p = 0.014), and emotional-behavioral dyscontrol (B = − 0.22, p = 0.019). Age was associated with all PROMIS outcomes (p ≤ 0.042). AFE was not associated with the prevalence of anxiety, depression, dementia, or mild cognitive impairment (p ≥ 0.449), while age was (p ≤ 0.013).

Conclusions

AFE was significantly associated with PROMIS outcomes, albeit low-strength associations (i.e., effect sizes), but not with diagnoses. Our findings indicate AFE is a significant but minor contributing factor for health-related quality of life in this cohort. Future work should incorporate additional characterizations of cumulative head impacts and related factors when examining long-term outcomes associated with football participation.

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Acknowledgements

The authors are grateful to Candice Goerger, Hope Campbell, and Caprice Hunt for their invaluable efforts in the administration, coordination, and execution of the NFL-LONG study. We extend special thanks to members of the NFL Alumni Association and Legends community for their assistance in recruitment of study participants. Further, we would like to thank each of the clinicians, researchers, educators, and former players who helped us adapt and develop the current general health survey.

Author information

Authors and Affiliations

  1. Division of Sports Medicine, Boston Children’s Hospital, Boston, MA, USA

    Landon B. Lempke & William P. Meehan III

  2. The Micheli Center for Sports Injury Prevention, Waltham, MA, USA

    Landon B. Lempke & William P. Meehan III

  3. School of Kinesioloy, Michigan Concussion Center, Ann Arbor, MI, USA

    Landon B. Lempke

  4. Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, 313 Woollen Gym, CB#8700, Chapel Hill, NC, 27599-8700, USA

    Samuel R. Walton, J. D. DeFreese, Kevin M. Guskiewicz & Zachary Yukio Kerr

  5. Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA

    Benjamin L. Brett & Michael A. McCrea

  6. Datalys Center for Sports Injury Research and Prevention, Indianapolis, IN, USA

    Avinash Chandran

  7. Departments of Emergency Medicine and Pediatrics, Harvard Medical School, Boston, MA, USA

    Rebekah Mannix

  8. Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA

    Rebekah Mannix

  9. Psychological and Neurobehavioral Associates, Inc, State College, PA, USA

    Ruben J. Echemendia

  10. University of Missouri-Kansas City, Kansas City, MO, USA

    Ruben J. Echemendia

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  1. Landon B. Lempke
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Corresponding author

Correspondence to Zachary Yukio Kerr.

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Author contributions

All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Specific author contributions are as follows: LBL: established research hypotheses, planned analyses of the data, interpretation of study findings, manuscript preparation and revision, final approval of the submitted manuscript. SRW, BLB, AC, and ZYK: creation and distribution of the study survey, management of study database, established research hypotheses, planned analyses of the data, interpretation of study findings, manuscript preparation and revision, final approval of the submitted manuscript. JDD, RCM, RJE, MAM, KMG, and WPM III: creation and distribution of the study survey, interpretation of study findings, manuscript preparation and revision, final approval of the submitted manuscript. Other contributors to the project are as follows (included in acknowledgements): Candice Goerger, Project Administrator: Assisted in the creation and distribution of the survey instrument as well as collection and management of the survey responses. Additionally, she was responsible for overseeing the project administration and execution. Hope Campbell, Project Coordinator (Medical College of Wisconsin): Assisted in the creation and distribution of the survey instrument as well as collection and management of the survey responses. Additionally, she assisted with oversight of the project administration and execution. Caprice Hunt, Project Coordinator (University of North Carolina at Chapel Hill): Assisted in the creation and distribution of the survey, oversight of the project administration, and execution of the study.

Funding

The parent study from which these data were drawn (NFL-LONG) was funded by the National Football League (NFL) as awarded to Drs. Meehan (PI) McCrea (Co-PI) and Guskiewicz (Co-PI). The sponsor provided no input into the present study, data analyses, or preparation of this article.

Conflict of interest

For complete transparency, the authors report the following potential conflicts of interest. Dr. Lempke reports current or prior support from the National Athletic Trainers’ Association, Southeast Athletic Trainers’ Association, Eastern Athletic Trainers’ Association, and the American College of Sport Medicine. Dr. Brett acknowledges support from the National Institutes of Health (NIH)—National Institute of Neurological Disorders and Stroke (award number L30 NS113158-02) and the National Institute on Aging (award number K23AG073528-01). Dr. Chandran receives funding from the National Collegiate Athletics Association (NCAA) as Director of the NCAA Injury Surveillance Program, and acknowledges funding from the Atlantic Coast Conference. Dr. DeFreese acknowledges support from the Atlantic Coast Conference and the Association for Applied Sport Psychology. Dr. Echemendia is (1) a paid consultant for the National Hockey League (NHL) and co-chair of the NHL/NHL Player’s Association Concussion Subcommittee, (2) a paid consultant for Major League Soccer (MLS), the US Soccer Federation, and Princeton University Athletic Medicine, and (3) occasionally provides expert testimony in matters related to mild traumatic brain injury and sports concussion. Dr. McCrea reports grants from NIH, Veterans Affairs, Centers for Disease Control and Prevention (CDC), Abbott Laboratories, Department of Defense (DoD), and NCAA outside the submitted work. Dr. Mannix acknowledges support from the NIH—National Institute of Neurologic Disorders and Stroke (U01NS096835), The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NS115942-01A1), the DoD (W81XWH1920011), and Abbott Pharmaceuticals. Dr. Meehan receives royalties from (1) ABC-Clio publishing for the sale of his books, Kids, Sports, and Concussion: A guide for coaches and parents, and Concussions; (2) Springer International for the book Head and Neck Injuries in Young Athletes, and (3) Wolters Kluwer for working as an author for UpToDate. His research is funded, in part, by philanthropic support from the National Hockey League Alumni Association through the Corey C. Griffin Pro-Am Tournament and a grant from the National Football League. Dr. Kerr reports support from CDC, DoD, and NIH. All authors declare no other potential conflicts of interest.

Availability of data and material

The dataset is not available for public sharing or upon individual’s reasonable requests due to privacy and sharing restrictions from the IRB.

Research involving human participants

The study was performed in accordance with the standards of ethics outlined in the Declaration of Helsinki.

Informed consent

All study procedures were reviewed and approved by the University of North Carolina-Chapel Hill’s IRB, as well the local IRB at each of the performance sites. Completion of the questionnaire after the introductory paragraph implied consent.

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Lempke, L.B., Walton, S.R., Brett, B.L. et al. Relating American Football Age of First Exposure to Patient-Reported Outcomes and Medical Diagnoses Among Former National Football League Players: An NFL-LONG study. Sports Med 53, 1073–1084 (2023). https://doi.org/10.1007/s40279-022-01795-9

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