Brain injury-related fatalities in American football, 1945-1999.
OBJECTIVE
Brain injuries have been the most common direct cause of death among American football players since the annual recording of football-related deaths began in 1931. This study examines the 55-year experience with brain injury-related fatalities in American football from 1945 to 1999, including not only the incidence but also the cause of death in discrete 5-year spans to focus on the variables that have either increased or decreased fatalities. In addition, we describe the types of injuries that have occurred, the activities in which the players were engaged at the time of injury, the level of play involved, and whether the injuries occurred during games or in practice sessions.


METHODS
Data were collected nationwide regarding football fatalities in all organized football programs in public schools and in college, professional, and youth programs by conducting personal interviews and eliciting responses to questionnaires. The information collected included demographic data about the injured player, equipment data, injury type and body part involved, and pertinent information regarding the exact circumstances of the accident.


RESULTS
We found that a total of 497 brain injury-related fatalities occurred among American football players during the period from 1945 through 1999. The causes of death were brain injuries in 69% of the cases, cervical spine injuries in 16%, and other injuries in 15%. Subdural hematoma was the type of injury associated with the majority (429, 86%) of brain injury-related fatalities. A majority (61%) of the brain injury-related fatalities occurred during participation in football games, and 75% of these were high school players. It should be noted that the number of high school football players is far greater (more than 1 million) than the number of either college (approximately 75,000) or professional (approximately 2000) players. The most frequent on-field activity involved when players sustained their fatal injuries was either tackling or being tackled (35%).


CONCLUSIONS
Brain injury-related fatalities accounted for 69% of all football fatalities from 1945 through 1999. The greatest number and percentage of brain injury-related fatalities occurred during the 5-year span from 1965 through 1969, and the smallest number and percentage occurred during the 2 decades from 1975 through 1994. Most brain injury-related fatalities involved a subdural hematoma sustained by high school football players while either tackling or being tackled in a game. In the 2 decades from 1975 through 1994, there was a dramatic reduction in these fatalities, and the preventive measures that have received most of the credit are 1) the 1976 rule change that prohibits initial contact with the head and face when blocking and tackling and 2) the National Operating Committee on Standards for Athletic Equipment helmet standard, which went into effect in colleges in 1978 and in high schools in 1980.
Cantu
Robert C
RC
Neurosurgery Service, Emerson Hospital, Concord, Massachusetts 01742, USA. rcantu@emersonhosp.org
Mueller
Frederick O
FO
D000293:Adolescent; D000328:Adult; D001265:Athletic Injuries / Q000401:mortality* / Q000517:prevention & control; D001930:Brain Injuries / Q000401:mortality* / Q000517:prevention & control; D002423:Cause of Death; D002574:Cervical Vertebrae / Q000293:injuries; D005538:Football / Q000293:injuries*; D006408:Hematoma, Subdural / Q000401:mortality / Q000517:prevention & control; D006801:Humans; D015994:Incidence; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D016103:Spinal Fractures / Q000401:mortality / Q000517:prevention & control; D014481:United States