CTE in U.S. Football

By Cross Warnock

Jeffery Miller (David J. Phillip/AP)

The increase in medical research on chronic traumatic encephalopathy (CTE) gives reason to believe in a potential link to the health of U.S. football players.

According to Arizona Law Review, Jeffrey Miller, the NFL’s senior vice president for Health and Safety Policy, said there was a correlation between football and degenerative brain disorders like CTE before the U.S. House of Representatives Energy and Commerce Committee on March 14, 2016.

Ann McKee, an expert in CTE research from Boston University, also testified and said she diagnosed CTE in 90 out of the 94 brains she examined from deceased former NFL players.

McKee stated a high percentage of NFL players will develop CTE; however, she has no idea what percent of former NFL players have CTE because her collection of brains is not representative of the former NFL population.

The article mentioned the majority of CTE cases in these studies were associated with repetitive head trauma which can take place from multiple concussions.

Madeline Uretsky, senior research assistant at Boston University, indicated the primary risk factor for developing CTE is repetitive head impacts.

“Whenever you are doing an activity with hundreds to thousands of hits to the head over time,” Uretsky said, “CTE is more likely.”

Rich Jones, former neurology nurse practitioner, said the brain experiences coup and contrecoup when a forceful collision occurs.

Rich Jones, former neurology nurse practitioner (Photo by Cross Warnock)

“The frontal and temporal lobes bash into boney protuberances inside the skull; that’s called a coup injury,” Jones said. “You can get the same thing happening with the occipital lobe when the back of the brain bumps into the back skull; that’s called contrecoup.”

The frontal lobe is responsible for reasoning, motor control, emotion and language; the temporal lobe is associated with hearing, memory, emotion and some aspects of language; and the occipital lobe is the major visual processing center and interprets depth, distance, location and sight.

According to Frontiers in Neurology, 61% of NFL players have experienced at least one concussion in their career.

The article revealed multiple concussions are a risk factor for cognitive neurodegeneration and adverse effects on mental health, which may predispose individuals to develop CTE.

Symptoms of CTE include the following: irritability, aggression, episodic memory impairment, cognitive dysfunction, suicidal ideation, rampant mood fluctuations and depression.

A former player who suffered from these symptoms was NFL Hall of Famer Junior Seau.

Junior Seau (Jim McIsaac/Getty Images)

According to World Neurosurgery, Seau’s ex-wife revealed he complained of headaches, episodes of dizziness and insomnia as early as the 1990s.

“When he would come home from games, he would go straight to the room,” she said, “lower the blinds, the blackout blinds, and just say ‘Quiet, my head is, is burning.’”

After his retirement in 2010, the article mentioned his family and friends reported behavioral changes that included: withdrawal, heavy alcohol consumption, reckless business and financial decisions and gambling. Seau also became more aggressive and sometimes violent with his close friends and family, which was uncharacteristic of him.

On May 2, 2012, Seau was found dead from apparent suicide at age 43.

Seau’s brain was donated by family and examined at the National Institutes of Health, National Institute of Neurological Disorders and Stroke in July 2012.

The article stated neuropathologic analyses of Seau’s brain revealed multi-focal tauopathy consistent with a diagnosis of chronic traumatic encephalopathy.

The article concluded Seau’s case and other studies implicates the role of repetitive brain impacts as a potential risk factor for CTE.

Jones said he believes football causes CTE but for a certain subset.

“The question is, who’s in that subset?” Jones said. “If we know certain predisposing factors like x, y or z give someone a 40% greater chance of having CTE, it might make them think twice about continuing to play football.”

Jones said you are seeing more young players retire early because they do not want to increase their chance of getting CTE.

“Thing is,” Jones said, “they may have already had enough bumps on their head to put them at risk.”

Charles Golden, author of “Chronic Traumatic Encephalopathy (CTE) Impact on Brains, Emotions, and Cognition,” said CTE impacts people differently because of individual factors we do not fully understand yet.

“Some people don’t show the effects of CTE until 20 years after they play,” Golden said, “and some of them show it very rapidly.”

Charles Golden (Nova Southeastern University Website)

Golden said there is an assumption that everyone is the same, but it is likely some people are more prone to developing CTE.

“They need to do more research into what these characteristics are,” Golden said. “A few examples are the way the person plays, the way their brain is set up and the existence of preexisting disorders.”

Uretsky said Boston University is currently examining other factors that make someone susceptible to CTE.

“[Factors include] genetics, substance use history, education, decade of play and age,” Uretsky said. “We have done studies examining length of playing career and age one starts playing football.”

According to JAMA Network, a study by Jesse Mez, assistant professor of neurology at Boston University, found 177 out of 202 deceased football players to have CTE.

Jesse Mez (Boston University)

Of the diagnosed, three played in high school, seven in the Canadian Football League (CFL), nine in semiprofessional leagues, 48 in college and 110 in the NFL.

More data from the article indicated 44 of the 177 experienced mild CTE while the rest suffered from severe CTE.

Suicide was the highest cause of death (27%) for those with mild CTE. Meanwhile, neurodegeneration (47%) was the highest among players with severe CTE.

In an interview with JAMA Network, retired NFL running back Mike Adamle said he does what he can to combat the depression, frustration and forgetfulness he faces from CTE with exercise, diet and cognitive stimulation.

“We’ve got sort of a fraternity of players who call each other up whenever we need it,” Adamle said, “because you do really get paranoid and depressed.”

Adamle concluded he would like to see football become safer but doesn’t know when change will happen.

“Whether they can do that over a period of time, in the next 20 years,” Adamle said, “I’m not certain and I don’t think anyone is certain.”

However, the NFL is taking action.

Uretsky mentioned the NFL has taken appropriate steps to make the game safer, but players will always be at risk of CTE.

“The only way to not get CTE is to not get hit in the head,” Uretsky said. “Hitting is fundamental in football, so there will always be a risk.”

According to NFL Player Health & Safety, there were 281 concussions in 2017, 214 in 2018 and 224 in 2019.

Total concussions throughout NFL seasons (Cross Warnock)

Christina Mack, vice president for the NFL’s Health and Safety Policy, said there was a 24% drop in concussions from 2017 to 2018 due to the injury reduction plan, which was deployed before the 2018 season.

The purpose of this plan was to reduce the amount of concussions by educating players, providing better performing helmets and changing certain rules to ensure safety.

One rule change was the creation of a “head targeting rule,” which penalizes a team 15 yards if a player lowers his helmet when initiating contact with an opponent. The player will also be ejected for the remainder of the game and receive a fine.

Mack mentioned this decrease was a new benchmark and happened because of the reduction efforts.

Christina Mack (NFL Player Health & Safety)

Miller explained there are three types of helmets: green, yellow and red. Green is best-performing, yellow is permissible and red is prohibited.

“This year, we saw 99% of players wearing green,” Miller said. “Two years ago, 41% of our players were in the green.”

Golden said while the NFL has improved its protocol, there are still weaknesses.

“It doesn’t look at more complex remaining deficits that people may show,” Golden said. “There are players with both emotional and cognitive problems that are reasonably serious that they aren’t paying attention to.”

Golden also noted there is a weakness with the baseline testing done at the beginning of every season.

“After a player is injured, they can’t play until they return to their baseline,” Golden said. “Some players deliberately do poorly so when they get injured it isn’t difficult for them to meet those levels even though they still actually have a concussion.”