Sports Medicine

, Volume 49, Issue 3, pp 477–487 | Cite as

Estimated Age of First Exposure to American Football and Neurocognitive Performance Amongst NCAA Male Student-Athletes: A Cohort Study

  • Jaclyn B. Caccese
  • Ryan M. DeWolf
  • Thomas W. Kaminski
  • Steven P. Broglio
  • Thomas W. McAllister
  • Michael McCrea
  • Thomas A. BuckleyEmail author
  • CARE Consortium Investigators
Original Research Article
Part of the following topical collections:
  1. The NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium



Repetitive head impacts in young athletes are potentially detrimental to later life (e.g., age 50 + years) neurological function; however, it is unknown what the short-term effects (e.g., age 20 years) are in collegiate student-athletes.


The purpose of this study was to determine the effect of the estimated age of first exposure to American tackle football participation on neurocognitive performance and symptom severity scores in collegiate student-athletes.


We used a cohort study in which neurocognitive performance was assessed using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) test in 4376 male athletes (age 19.3 ± 1.5 years, mass 96.3 ± 20.3 kg, height 185.0 ± 7.4 cm). Athletes were grouped by sport participation [American football (n = 3462) or non-contact (n = 914)] and estimated age of first exposure [< 12 years (n = 3022) or ≥ 12 years (n = 1354)]. The outcome measures were the four primary cognitive scores and the symptom severity score from ImPACT. We assessed primary outcomes across groups, controlling for age, learning accommodations, and concussion history.


Neurocognitive performance was not associated with the estimated age of first exposure-by-group interaction.


Our findings indicate that participation in American tackle football before age 12 years does not result in neurocognitive deficits in college. Therefore, we suggest the following: the consequences of early exposure to repetitive head impacts do not manifest by college, the ImPACT test was not sensitive enough to identify the effects of an earlier estimated age of first exposure, or there is no association between an earlier estimated age of first exposure and neurocognitive functioning. Future longitudinal studies are warranted.



Contributing CARE Consortium Investigators include: April Marie (Reed) Hoy, MS, ATC (Azusa Pacific University); Joseph B. Hazzard Jr, EdD, ATC (Bloomsburg University); Louise A. Kelly, PhD (California Lutheran University); Justus D. Ortega, PhD (Humboldt State University); Nicholas Port, PhD (Indiana University); Margot Putukian MD (Princeton University); T. Dianne Langford, PhD (Temple University); Holly J. Benjamin MD (University of Chicago); James R. Clugston, MD, MS (University of Florida); Julianne D. Schmidt, PhD, ATC (University of Georgia); Luis A. Feigenbaum, DPT, ATC (University of Miami); James T. Eckner, MD, MS (University of Michigan); Jason P. Mihalik, PhD, CAT(C), ATC (University of North Carolina at Chapel Hill); Jessica Dysart Miles, PhD, ATC (University of North Georgia); Scott Anderson, ATC (University of Oklahoma); Christina L. Master, MD (University of Pennsylvania); Micky Collins, PhD, and Anthony P. Kontos, PhD (University of Pittsburgh Medical Center); Sara P.O. Chrisman, MD, MPH (University of Washington); Alison Brooks, MD, MPH (University of Wisconsin-Madison); Jonathan Jackson, MD, and Gerald McGinty, DPT (United States Air Force Academy); Kenneth Cameron, PhD, MPH, ATC (United States Military Academy); Adam Susmarski, MD (United States Naval Academy); Stefan Duma, PhD and Steve Rowson, PhD (Virginia Tech); Christopher M. Miles, MD (Wake Forest University); Brian H. Dykhuizen, MS, ATC (Wilmington College); Laura Lintner DO (Winston-Salem University). The authors also thank the research and medical staff at each of the participating sites.

Compliance with Ethical Standards


This publication was made possible, in part, with support from the Grand Alliance CARE Consortium, funded by the National Collegiate Athletic Association and the Department of Defence. The United States Army Medical Research Acquisition Activity, Ford Detrick, MD, USA is the awarding and administering acquisition office. This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs through the Psychological Health and Traumatic Brain Injury Program under Award No. W81XWH-14-2-0151. Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the Department of Defense (Defense Health Program funds).

Conflict of interest

Beyond the research grant received, in part for this work (described under funding), Jaclyn B. Caccese, Ryan M. DeWolf, Thomas W. Kaminski, Steven P. Broglio, Thomas W. McAllister, Michael McCrea, and Thomas A. Buckley have no conflicts of interest that are directly relevant to the content of this study.

Ethics approval

The study was performed in accordance with the standards of ethics outlined in the Declaration of Helsinki. All study procedures were reviewed by the University of Michigan Institutional Review Board, the US Army Medical Research and Materiel Command Human Research Protection Office, as well as the local institutional review board at each of the performance sites.

Consent to participate

Participants provided written informed consent prior to participation.

Data availability

The CARE Consortium datasets generated and analyzed during the current study will be available in the Federal Interagency Traumatic Brain Injury Research repository ( by the end of 2019.


  1. 1.
    Daniel RW, Rowson S, Duma SM. Head impact exposure in youth football. Ann Biomed Eng. 2012;40(4):976–81.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Powell JW, Barber-Foss KD. Traumatic brain injury in high school athletes. JAMA. 1999;282(10):958–63.PubMedGoogle Scholar
  3. 3.
    Guskiewicz KM, Weaver NL, Padua DA, Garrett WE. Epidemiology of concussion in collegiate and high school football players. Am J Sports Med. 2000;28(5):643–50.PubMedGoogle Scholar
  4. 4.
    McCrea M, Guskiewicz KM, Marshall SW, Barr W, Randolph C, Cantu RC, et al. Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. JAMA. 2003;290(19):2556–63.PubMedGoogle Scholar
  5. 5.
    Manley GT, Gardner AJ, Schneider KJ, Guskiewicz KM, Bailes J, Cantu RC, et al. A systematic review of potential long-term effects of sport-related concussion. Br J Sports Med. 2017;51(12):969–77.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Bailes JE, Petraglia AL, Omalu BI, Nauman E, Talavage T. Role of subconcussion in repetitive mild traumatic brain injury: a review. J Neurosurg. 2013;119(5):1235–45.PubMedGoogle Scholar
  7. 7.
    Belanger HG, Vanderploeg RD, McAllister T. Subconcussive blows to the head: a formative review of short-term clinical outcomes. J Head Trauma Rehabil. 2016;31(3):159–66.PubMedGoogle Scholar
  8. 8.
    Erlanger DM. Exposure to sub-concussive head injury in boxing and other sports. Brain Inj. 2015;29(2):171–4.PubMedGoogle Scholar
  9. 9.
    Broglio SP, Eckner JT, Martini D, Sosnoff JJ, Kutcher JS, Randolph C. Cumulative head impact burden in high school football. J Neurotrauma. 2011;28(10):2069–78.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Cobb BR, Urban JE, Davenport EM, Rowson S, Duma SM, Maldjian JA, et al. Head impact exposure in youth football: elementary school ages 9–12 years and the effect of practice structure. Ann Biomed Eng. 2013;41(12):2463–73.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Mihalik JP, Bell DR, Marshall SW, Guskiewicz KM. Measurement of head impacts in collegiate football players: a investigation of positional and event-type differences. Neurosurgery. 2007;61(6):1229–35.PubMedGoogle Scholar
  12. 12.
    Crisco JJ, Wilcox BJ, Beckwith JG, Chu JJ, Duhaime A, Rowson S, et al. Head impact exposure in collegiate football players. J Biomech. 2011;44(15):2673–8.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Crisco JJ, Fiore R, Beckwith JG, Chu JJ, Brolinson PG, Duma S, et al. Frequency and location of head impact exposures in individual collegiate football players. J Athl Train. 2010;45(6):549–59.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Montenigro PH, Alosco ML, Martin BM, Daneshvar DH, Mez J, Chaisson CE, et al. Cumulative head impact exposure predicts later-life depression, apathy, executive dysfunction, and cognitive impairment in former high school and college football players. J Neurotrauma. 2017;34(2):328–40.PubMedPubMedCentralGoogle Scholar
  15. 15.
    McCrory P, Meeuwisse W, Dvorak J, Aubry M, Bailes J, Broglio S, et al. Consensus statement on concussion in sport: the 5th International Conference on Concussion in Sport held in Berlin, October 2016. Br J Sports Med. 2017;51:838–47.PubMedGoogle Scholar
  16. 16.
    Mez J, Daneshvar DH, Kiernan PT, Abdolmohammadi B, Alvarez VE, Huber BR, et al. Clinicopathological evaluation of chronic traumatic encephalopathy in players of American football. JAMA. 2017;318(4):360–70.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Lehman EJ, Hein MJ, Gersic CM. Suicide mortality among retired national football league players who played 5 or more seasons. Am J Sports Med. 2016;44(10):2486–91.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Janssen PH, Mandrekar J, Mielke MM, Ahlskog JE, Boeve BF, Josephs K, et al. High school football and late-life risk of neurodegenerative syndromes, 1956–1970. Mayo Clin Proc. 2017;92(1):66–71.PubMedGoogle Scholar
  19. 19.
    Kuhn AW, Zuckerman SL, Solomon GS, Casson IR, Viano DC. Interrelationships among neuroimaging biomarkers, neuropsychological test data, and symptom reporting in a cohort of retired national football league players. Sports Health. 2017;9(1):30–40.PubMedGoogle Scholar
  20. 20.
    Stamm JM, Koerte IK, Muehlmann M, Pasternak O, Bourlas AP, Baugh CM, et al. Age at first exposure to football is associated with altered corpus callosum white matter microstructure in former professional football players. J Neurotrauma. 2015;32(22):1768–76.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Schultz V, Stern RA, Tripodis Y, Stamm JM, Wrobel P, Lepage C, et al. Age at first exposure to repetitive head impacts is associated with smaller thalamic volumes in former professional American football players. J Neurotrauma. 2017;35(2):278–85.PubMedGoogle Scholar
  22. 22.
    Stamm JM, Bourlas AP, Baugh CM, Fritts NG, Daneshvar DH, Martin BM, et al. Age of first exposure to football and later-life cognitive impairment in former NFL players. Neurology. 2015;84(11):1114–20.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Alosco ML, Kasimis AB, Stamm JM, Chua AS, Baugh CM, Daneshvar DH, et al. Age of first exposure to American football and long-term neuropsychiatric and cognitive outcomes. Transl Psychiatry. 2017;7(9):e1236.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Solomon GS, Kuhn AW, Zuckerman SL, Casson IR, Viano DC, Lovell MR, et al. Participation in pre-high school football and neurological, neuroradiological, and neuropsychological findings in later life: a study of 45 retired National Football League players. Am J Sports Med. 2016;44(5):1106–15.PubMedGoogle Scholar
  25. 25.
    Epstein HT. Stages of increased cerebral blood flow accompany stages of rapid brain growth. Brain Dev. 1999;21(8):535–9.PubMedGoogle Scholar
  26. 26.
    Giedd JN, Blumenthal J, Jeffries NO, Castellanos FX, Liu H, Zijdenbos A, et al. Brain development during childhood and adolescence: a longitudinal MRI study. Nat Neurosci. 1999;2(10):861–3.PubMedGoogle Scholar
  27. 27.
    Lebel C, Walker L, Leemans A, Phillips L, Beaulieu C. Microstructural maturation of the human brain from childhood to adulthood. Neuroimage. 2008;40(3):1044–55.PubMedGoogle Scholar
  28. 28.
    Uematsu A, Matsui M, Tanaka C, Takahashi T, Noguchi K, Suzuki M, et al. Developmental trajectories of amygdala and hippocampus from infancy to early adulthood in healthy individuals. PLoS One. 2012;7(10):e46970.PubMedPubMedCentralGoogle Scholar
  29. 29.
    Chugani HT, Phelps ME, Mazziotta JC. Positron emission tomography study of human brain functional development. Ann Neurol. 1987;22(4):487–97.PubMedGoogle Scholar
  30. 30.
    Shaw P, Greenstein D, Lerch J, Clasen L, Lenroot R, Gogtay N, et al. Intellectual ability and cortical development in children and adolescents. Nature. 2006;440(7084):676–9.PubMedGoogle Scholar
  31. 31.
    Zeigler DW, Wang CC, Yoast RA, Dickinson BD, McCaffree MA, Robinowitz CB, et al. The neurocognitive effects of alcohol on adolescents and college students. Prev Med. 2005;40(1):23–32.PubMedGoogle Scholar
  32. 32.
    Kelly KC, Jordan EM, Joyner AB, Burdette GT, Buckley TA. National collegiate athletic association division I athletic trainers’ concussion-management practice patterns. J Ath Train. 2014;49(5):665–73.Google Scholar
  33. 33.
    Alsalaheen B, Stockdale K, Pechumer D, Broglio SP. Validity of the Immediate Post Concussion Assessment and Cognitive Testing (ImPACT). Sports Med. 2016;46(10):1487–501.PubMedGoogle Scholar
  34. 34.
    Broglio SP, Katz BP, Zhao S, McCrea M, McAllister T, CARE Consortium Investigators. Test–retest reliability and interpretation of common concussion assessment tools: findings from the NCAA-DoD CARE consortium. Sports Med. 2017;48(5):1255–68.PubMedCentralGoogle Scholar
  35. 35.
    Buckley TA, Burdette G, Kelly K. Concussion-management practice patterns of national collegiate athletic association division II and III athletic trainers: how the other half lives. J Athl Train. 2015;50(8):879–88.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Broglio SP, McCrea M, McAllister T, Harezlak J, Katz B, Hack D, et al. A national study on the effects of concussion in collegiate athletes and US military service academy members: the NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium structure and methods. Sports Med. 2017;47(7):1437–51.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Katz BP, Kudela M, Harezlak J, McCrea M, McAllister T, Broglio SP, CARE Consortium Investigators. Baseline performance of NCAA athletes on a concussion assessment battery: a report from the CARE consortium. Sports Med. 2018;48(8):1971–85.PubMedGoogle Scholar
  38. 38.
    Catenaccio E, Caccese J, Wakschlag N, Fleysher R, Kim N, Kim M, et al. Validation and calibration of HeadCount, a self-report measure for quantifying heading exposure in soccer players. Res Sports Med. 2016;24(4):416–25.PubMedPubMedCentralGoogle Scholar
  39. 39.
    Caccese JB, Lamond LC, Buckley TA, Kaminski TW. Reducing purposeful headers from goal kicks and punts may reduce cumulative exposure to head acceleration. Res Sports Med. 2016;24(4):407–15.PubMedGoogle Scholar
  40. 40.
    Caccese JB, Kaminski TW. Minimizing head acceleration in soccer: a review of the literature. Sports Med. 2016;46(11):1591–604.PubMedGoogle Scholar
  41. 41.
    Caccese JB, Kaminski TW. Neurocognitive changes in men’s and women’s soccer players across a collegiate career. In: Favero T, Drust B, Dawson B, editors. International research in science and soccer II. New York: Routledge; 2015. p. 133–44.Google Scholar
  42. 42.
    Lovell M. ImPACT 2007 (6.0) clinical interpretation manual. Pittsburgh: ImPACT Applications; 2007.Google Scholar
  43. 43.
    Bruce J, Echemendia R, Meeuwisse W, Comper P, Sisco A. 1 year test–retest reliability of ImPACT in professional ice hockey players. Clin Neuropsychol. 2014;28(1):14–25.PubMedGoogle Scholar
  44. 44.
    Elbin RJ, Schatz P, Covassin T. One-year test–retest reliability of the online version of ImPACT in high school athletes. Am J Sports Med. 2011;39(11):2319–24.PubMedGoogle Scholar
  45. 45.
    Iverson GL, Lovell MR, Collins MW. Validity of ImPACT for measuring processing speed following sports-related concussion. J Clin Exp Neuropsychol. 2005;27(6):683–9.PubMedGoogle Scholar
  46. 46.
    Resch J, Driscoll A, McCaffrey N, Brown C, Ferrara MS, Macciocchi S, et al. ImPact test–retest reliability: reliably unreliable? J Athl Train. 2013;48(4):506–11.PubMedPubMedCentralGoogle Scholar
  47. 47.
    Schatz P, Sandel N. Sensitivity and specificity of the online version of ImPACT in high school and collegiate athletes. Am J Sports Med. 2013;41(2):321–6.PubMedGoogle Scholar
  48. 48.
    Schatz P, Pardini JE, Lovell MR, Collins MW, Podell K. Sensitivity and specificity of the ImPACT test battery for concussion in athletes. Arch Clin Neuropsychol. 2006;21(1):91–9.PubMedGoogle Scholar
  49. 49.
    Schatz P, Ferris CS. One-month test–retest reliability of the ImPACT test battery. Arch Clin Neuropsychol. 2013;28(5):499–504.PubMedGoogle Scholar
  50. 50.
    Schatz P. Long-term test–retest reliability of baseline cognitive assessments using ImPACT. Am J Sports Med. 2010;38(1):47–53.PubMedGoogle Scholar
  51. 51.
    Nakayama Y, Covassin T, Schatz P, Nogle S, Kovan J. Examination of the test–retest reliability of a computerized neurocognitive test battery. Am J Sports Med. 2014;42(8):2000–5.PubMedGoogle Scholar
  52. 52.
    Maerlender A, Flashman L, Kessler A, Kumbhani S, Greenwald R, Tosteson T, et al. Discriminant construct validity of ImPACT™: a companion study. Clin Neuropsychol. 2013;27(2):290–9.PubMedPubMedCentralGoogle Scholar
  53. 53.
    Maerlender A, Flashman L, Kessler A, Kumbhani S, Greenwald R, Tosteson T, et al. Examination of the construct validity of ImPACT™ computerized test, traditional, and experimental neuropsychological measures. Clin Neuropsychol. 2010;24(8):1309–25.PubMedPubMedCentralGoogle Scholar
  54. 54.
    Lau BC, Collins MW, Lovell MR. Sensitivity and specificity of subacute computerized neurocognitive testing and symptom evaluation in predicting outcomes after sports-related concussion. Am J Sports Med. 2011;39(6):1209–16.PubMedGoogle Scholar
  55. 55.
    Broglio SP, Macciocchi SN, Ferrara MS. Sensitivity of the concussion assessment battery. Neurosurgery. 2007;60(6):1050–8.PubMedGoogle Scholar
  56. 56.
    Allen BJ, Gfeller JD. The immediate post-concussion assessment and cognitive testing battery and traditional neuropsychological measures: a construct and concurrent validity study. Brain Inj. 2011;25(2):179–91.PubMedGoogle Scholar
  57. 57.
    Broglio SP, Ferrara MS, Macciocchi SN, Baumgartner TA, Elliott R. Test–retest reliability of computerized concussion assessment programs. J Athl Train. 2007;42(4):509–14.PubMedPubMedCentralGoogle Scholar
  58. 58.
    Erdal K. Neuropsychological testing for sports-related concussion: how athletes can sandbag their baseline testing without detection. Arch Clin Neuropsychol. 2012;27(5):473–9.PubMedGoogle Scholar
  59. 59.
    Iverson GL, Lovell MR, Collins MW. Interpreting change on ImPACT following sport concussion. Clin Neuropsychol. 2003;17(4):460–7.PubMedGoogle Scholar
  60. 60.
    Iverson GL, Lovell MR, Collins MW. Immediate post-concussion assessment and cognitive testing (ImPACT) normative data. University of British Columbia and Riverview Hospital; 2003. Accessed 2 Jan 2018.
  61. 61.
    Alosco ML, Mez J, Tripodis Y, Kiernan PT, Abdolmohammadi B, Murphy L, et al. Age of first exposure to tackle football and chronic traumatic encephalopathy. Ann Neurol. 2018;83:886–901.PubMedGoogle Scholar
  62. 62.
    Smith PJ, Blumenthal JA, Hoffman BM, Cooper H, Strauman TA, Welsh-Bohmer K, et al. Aerobic exercise and neurocognitive performance: a meta-analytic review of randomized controlled trials. Psychosom Med. 2010;72(3):239–52.PubMedPubMedCentralGoogle Scholar
  63. 63.
    Trudeau F, Shephard RJ. Physical education, school physical activity, school sports and academic performance. Int J Behav Nutr Phys Act. 2008;5(1):10.PubMedPubMedCentralGoogle Scholar
  64. 64.
    Maroon JC, Bailes J, Collins M, Lovell M, Mathyssek C, Andrikopoulos J, et al. Age of first exposure to football and later-life cognitive impairment in former NFL players. Neurology. 2015;85(11):1007–10.PubMedGoogle Scholar
  65. 65.
    Broglio SP, Kontos AP, Levin H, Schneider K, Wilde EA, Cantu RC, et al. The National Institute of Neurological Disorders and Stroke and Department of Defense Sport-Related Concussion Common Data Elements Version 1.0 recommendations. J Neurotrauma. 2018;35(23):2776–83.PubMedGoogle Scholar
  66. 66.
    Martini DN, Broglio SP. Long-term effects of sport concussion on cognitive and motor performance: a review. Int J Psychophysiol. 2018;132(Pt A):25–30.PubMedGoogle Scholar
  67. 67.
    Stone AA, Bachrach CA, Jobe JB, Kurtzman HS, Cain VS. The science of self-report: implications for research and practice. London: Psychology Press; 1999.Google Scholar
  68. 68.
    Houck Z, Asken B, Clugston J, Perlstein W, Bauer R. Socioeconomic status and race outperform concussion history and sport participation in predicting collegiate athlete baseline neurocognitive scores. J Int Neuropsychol Soc. 2018;24(1):1–10.PubMedGoogle Scholar
  69. 69.
    Taylor KM, Kioumourtzoglou MA, Clover J, Coull BA, Dennerlein JT, Bellinger DC, Weisskopf MG. Concussion history and cognitive function in a large cohort of adolescent athletes. Am J Sports Med. 2018;46(13):3262–70.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Jaclyn B. Caccese
    • 1
  • Ryan M. DeWolf
    • 2
  • Thomas W. Kaminski
    • 1
    • 3
  • Steven P. Broglio
    • 4
  • Thomas W. McAllister
    • 5
  • Michael McCrea
    • 6
  • Thomas A. Buckley
    • 1
    • 3
    Email author
  • CARE Consortium Investigators
  1. 1.Department of Kinesiology and Applied PhysiologyUniversity of DelawareNewarkUSA
  2. 2.Massachusetts General Hospital, Institute of Health ProfessionsBostonUSA
  3. 3.Biomechanics and Movement Science Interdisciplinary ProgramUniversity of DelawareNewarkUSA
  4. 4.NeuroTrauma Research Laboratory, University of Michigan Injury CenterUniversity of MichiganAnn ArborUSA
  5. 5.Department of PsychiatryIndiana University School of MedicineIndianapolisUSA
  6. 6.Departments of Neurosurgery and NeurologyMedical College of WisconsinMilwaukeeUSA

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