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A University of Michigan football player, headed to the NFL, recently asked me what I thought about CTE (Chronic Traumatic Encephalopathy). Honestly, I had never thought about it, so I went to the UCLA brain bank, which is one of the most extensive in the world. I looked at some brains with CTE. They looked like brains with Alzheimer’s disease (AD). It made sense. Both AD and CTE are degenerative brain diseases resulting in similar behavior. The difference is repetitive brain trauma causes CTE, rather than genetics, which causes AD. The take home message of course—CTE generated dementia is preventable.
CTE causes a number of neurological and physiological changes in the brain including the buildup of an abnormal protein. This protein collects, clumps and disrupts brain function by obstructing signaling. When comparing the post mortem CTE brains of athletes and soldiers, the clumping was more localized in the athlete (in the frontal lobe) compared to the soldier where the clumping occurred all over the brain. This, I suspect is due to differences in the head trauma experienced by a football player on the line, compared to a soldier from a bomb or grenade.
Like any disease, the clinical symptoms of CTE vary depending on what stage the disease is in when it is diagnosed. Globally CTE affects cognitive function, and motor skills, e.g. attention, memory, concentration, walking and speaking. It also causes tremors, vertigo and deafness. CTE sufferers generally progress through three stages of the disease beginning in the first stage with affective disturbances and psychotic symptoms. Social instability, erratic behavior, memory loss, and the initial symptoms of Parkinson’s disease mark the second stage. The third stage of CTE presents as progressive deterioration to dementia and may have other symptoms including the signs associated with Parkinson’s disease: speech difficulties, gait abnormalities, difficulty swallowing, drooping eyelids, and dysarthria (a speech disorder from neuromuscular weakness or lack of control of facial muscles).
We can only definitively detect CTE in brain tissue microscopically. Hence, there are no markers for finding it in living athletes. However, there is research on pro athletes to develop a protocol for testing for CTE in live persons. They are trying diffusion tensor imaging, virtual biopsy, blood tests, and protein measures in spinal fluid. However, that is when, this is now. There is a no test for live athletes. That is concerning. However, this is more concerning: although CTE primarily presents in professional boxers, it now appears in wrestlers, lacrosse, football, and soccer players. A 2010 Center for the Study of Traumatic Encephalopathy (CSTE) found that 17 of the 18 dead contact sport athletes that they studied had CTE. While that is an alarming percentage, you must remember that this was just 18, of thousands, maybe millions of athletes (most of whom are alive) that play contact sports.
However, because repetitive head injuries seemingly cause CTE, contact sports place athletes at risk. Boxing, football, wrestling, rugby, hockey, lacrosse, soccer, and skiing are the highest risk sports. In addition, clinicians have identified CTE in epileptics, head bangers, and domestic abuse victims. While athletes in collision sports, (e.g. football and boxing) may have higher incidents of concussive and sub-concussive brain injuries, any athlete in any sport who may experience more than one concussive injury may be at risk for CTE; that is not good. Then again, while people who drink and drive may have higher incidence of traffic fatalities, anybody who gets behind the wheel of a car may die in an auto fatality. Reality Check: life is dangerous and has risks. In terms of CTE, because there is no test for CTE, there is no way to tell if an athlete who has experienced head trauma has CTE. We have to wait until he or she is dead.
We do not know how many concussive injuries it takes to begin the processes of permanent brain deterioration. All we know is that repetitive brain injury causes CTE. There are many questions that we need immediate answers to, such as: How many concussions does it take to cause CTE? How severe does the concussion have to be to cause CTE? How many repetitive concussions does it take to cause CTE? How long after an athlete receives his or her last concussion, does CTE begin to deteriorate the brain? Does CTE manifest differently in different athletes? Do different athletes have different tolerance levels for the predisposition to CTE? Fortunately, 250 NFL athletes have agreed to donate their brains after they die for research.
Research is great, but prevention is better, since we know the cause of CTE. The focus must be proper diagnosis, strict guidelines and adherence. Unfortunately, even the latest advances in concussion management may not be enough. According to Dr. Robert Stern, co-director of CSTE, “85% of concussions require about three weeks of recovery.” This time-period is longer than the current return-to-play guidelines. We need to fix this—yesterday.
Current guidelines recommend: a graduated increase in the level of activity of the athlete progressing from the initial stage of “light exercise” towards “full contact” activity once the athlete is completely symptom-free at rest. The athlete progresses through each stage as long as the athlete remains symptom-free during each stage. If symptoms return, then the athlete needs to stop for the day. This progression may conclude in as little as 5 days or may take as long as the athlete requires.
We need more research to ensure that the current neurological tests accurately and correctly correspond to the brain’s status. If concussed athletes’ brains still suffer concussive effects without corresponding outward signs or symptoms, then obviously we need better neurocognitive tests to accurately reflect the status of the brain. For football, reducing full-contact practices, changing the way players line up on the field, and using new helmets to reduce the force of head impact would help.
The best recommendation for the prevention of CTE is to ensure that sports medicine professionals who have clinical concussion-treatment experience see athletes who sustain concussions. You have a Defensive Coordinator because he knows defense. Likewise, you want a doctor who knows concussions. Medical research changes constantly. It is unrealistic to expect a primary care physician, who does not specialize in sports medicine, to correctly diagnose a concussion using the latest guidelines, diagnostic tools, and be versed in current treatment protocols. They might think they do—and probably will claim they do—but trust me the smart money is on they do not and will not.
Parents of athletes need to be most vigilant in learning the signs and symptoms of concussions as well as the diagnostic and treatment protocols. Being a parent is a much harder job than being a doctor, which is why I am not a parent (that and children get up in the morning). Anyway, it is an egregious error to leave your child’s well being up to doctors. Moreover, parents have the advantage of being able to observe subtle behavioral changes that doctors do not. If your doctor will listen to you, you need a new doctor, fire him or her, end of story—doctors are very replaceable—your child is not.
My casual mentoring of various Michigan football players over the past decade has changed my perspective on football. I have a much greater respect for the dedication, discipline and excellence needed to play at the Michigan level. Thus, I value the players more than game. Michigan is my alma mater, I am an alumni cheerleader, and I absolutely, love to do two things, as much as humanly possible; watching Michigan football is the other one. I chose Michigan over Stanford and Yale because of the football team.However, if I had to choose between any Michigan football player and Michigan football, it would be a no-brainer, good-bye Michigan football.
However, it does not need to come down to a Sophie’s-Choice moment. We can prevent CTE, and the onus lies, not just with football programs, coaches and parents, but also with the fans, and the billion-dollar industry of American football. HAIL! And of course… Remain Fabulous and Phenomenal.
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