Chronic traumatic encephalopathy (“CTE”) is a degenerative disease that is theoretically linked to repeat mild traumatic brain injuries (“TBI”). Since its discovery in 2002, CTE has been studied extensively, especially in regard to its prevalence in participants of certain sports. In recent years, football has been front and center of the discussion, as many former players were diagnosed with CTE posthumously. In light of recent findings, state lawmakers have begun proposing bans on youth tackle football, citing the recent CTE research that asserts the longer a player engages in tackle football, the more likely they are to develop the degenerative brain disease. This series is a deep dive into the issue, providing a foundation about traumatic brain injury and CTE, its effects on adults and children, notable cases and research findings regarding football players diagnosed with CTE, and the positions on the ban of youth tackle football.
The series concludes with a novel conclusion: blame the treatment, not the tackle. As the saying goes, “there isn’t smoke without fire.” Recently, with the prevalence of CTE in the news, popular culture, and the like, many began thinking “there isn’t CTE without the tackle.” This couldn’t be more off base. We really should be thinking of it as “there isn’t CTE without improper treatment.” Simply, the risk of brain degeneration due to improper treatment is far greater than the risk of injury from the hit itself.
Part 1 of the series focuses on defining and discussing traumatic brain injury and CTE, but in adults and children;
Part 2 of the series focuses on notable cases of CTE, as well as recent research into the disease;
Part 3 of the series discusses the proposals to ban youth tackle football; and
Part 4 of the series considers the truth about the research behind CTE and its limited scope in light of the spotlight it has received in pop culture and social media. The significant importance of proper protocol and treatment following head injuries is discussed, suggesting the possibility that CTE is not precipitated by the tackle itself, but rather poor treatment of the hit. Furthermore, it is not only the treatment, but the management of the treatment that needs serious attention. This is particularly true where treatment management can be addressed here and now and the possibility of CTE, although a valid concern, will never be definite until postmortem diagnosis, when it is too late to take direct action.
Traumatic Brain Injury and its Effects
Traumatic Brain Injury (“TBI”) is a major cause of death and disability in the United States. A TBI can be caused by any type of jolt or blow to the head and disrupts normal function of the brain. Mild TBIs are typically referred to as concussions and result in a brief change in mental status or consciousness. TBIs typically result in an extended period of unconsciousness or memory loss. A growing body of research shows that repeated concussions can cause permanent brain damage.
According to the Center for Disease Control and Prevention, in 2013, about 2.8 million TBI-related emergency department visits, hospitalizations, and deaths occurred in the United States. Possibly more concerning is that in 2012, an estimated 329,290 children age 19 or younger were treated in emergency departments for sports related injuries that included a diagnosis of concussion or TBI. Furthermore, from 2001 to 2012, the rate of emergency department visits for sports related injuries with a diagnosis of concussion or TBI more than doubled among children.
Symptoms and Effects
When an individual suffers a blow or jolt to the head, the brain can undergo a type of mini-seizure. Afterward, the brain shuts down to try to repair itself. It can take days or weeks for the brain to heal. The real danger is when an individual suffers a successive concussion during this “healing” period, which may result in a complication called “second impact syndrome.” Although second impact syndrome is rare, it is severe, as it causes the brain to swell significantly.
Barry S. Willer, PhD, Professor of Psychiatry at the University at Buffalo School of Medicine and Biomedical Sciences and Director of Research for the internationally renowned UB Concussion Clinic notes, “it is vital to understand second impact syndrome is not a term to describe what is simply repetitive impact.” Second impact syndrome speaks specifically to a rare complication of multiple, successive concussions that often lead to death. A repetitive impact does not necessarily mean the individual will develop second impact syndrome. Regardless, repetitive impacts during this healing process increase the likelihood of an individual suffering from a concussion and a longer healing period.
Hallmarks of TBI are confusion and amnesia. Once the occurrences of concussions begin to multiply in the same individual, symptoms of post-concussion syndrome will likely emerge. Symptoms of post-concussion syndrome include headaches, dizziness, difficulty concentrating, vertigo, and personality changes. Studies involving boxers and football players who have suffered multiple concussions have shown that even Parkinson-like symptoms and dementia may result.
In CTE, a protein called Tau forms and slowly spreads throughout the brain, killing brain cells. Symptoms of CTE do not generally begin appearing until years after the onset of head impacts. Early symptoms of CTE are typically those that affect an individual’s mood, behavior, and personality. Common symptoms are aggression, depression, paranoia, and inability to control impulses. As the disease progresses, many individuals will begin experiencing issues with thinking and memory, where progressive dementia may occur. These cognitive symptoms tend to appear later than the mood, behavior, and personality symptoms. However, development of these symptoms (including those associated with CTE) are not a “sure thing,” no matter what sport the individual engages in or how many hits he sustains.
CTE is diagnosed after death through brain tissue analysis. Doctors introduce chemicals to the brain that make the Tau clumps visible. Once visible, the brain can be analyzed for a unique pattern of Tau clumps that may indicate CTE.
Diagnosing CTE is not nearly as simple as popular culture makes people think; it is not like a doctor opens up the deceased’s head, looks at the brain, and exclaims, “there it is! CTE!” Not to mention, Tau may form in many other diseases, including Alzheimer’s, Pick disease, frontotemporal dementia, frontotemporal dementia with Parkinsonism-17, progressive supranuclear palsy, and corticobasal degeneration. Regardless of all of this medical terminology, one thing is certain: there are many forms of dementia that can result in a finding of Tau (the only indicator of CTE, which is discovered postmortem) and we don’t quite know what would classify it as definitively CTE or another disease, which that individual may have been predisposed to through genetics or other factors.
For the Love of Acronyms: The Difference Between Concussions, TBI, and CTE
Mild TBIs are typically categorized as concussions. However, not all TBIs are concussions, as TBIs can range from mild to severe. However, a term that has been tossed around in recent research is CTE. CTE is completely different than concussions or TBIs.
Chronic traumatic encephalopathy (“CTE”) is a degenerative disease that is tied to repeat mild TBIs. The research around CTE is growing rapidly, as scientists and doctors try to understand the disease. At this time, CTE can only be diagnosed after death when an autopsy of the brain reveals certain traits and characteristics. Although helpful, the current CTE research leaves many questions unanswered and should not be considered the final word on the link between repetitive concussions and later mental complications.
What Do We Actually Know About CTE?
In 1928, Dr. Harrison Martland described a group of boxers as having “punch drunk syndrome.” Over the next 75 years, other doctors and researchers described similar findings in boxers and other victims of TBI. Finally, in 2005, Bennet Omalu published the first real evidence of CTE when he studied the former Pittsburgh Steeler Mike Webster. Following this study, the Concussion Legacy Foundation, Boston University, and the U.S. Department of Veterans Affairs formed the VA-BU-CLF Brain Bank. Over the years, over 600 brains have been donated to VA-BU-CLF, with more than 360 of those having been found to have CTE. These results are offered with caution, as other scientists have not confirmed these results (there are less than a handful of people who orchestrate this research) and there is little information regarding what other diseases may have caused these results and each individual’s predisposition to these diseases. It also should be noted that the brains that are donated or solicited to be donated to BU for the studies are self-selecting. Therefore, the families donating these brains and the University studying these brains have an interest in discovering CTE given the supposed proclivity for CTE from their own understanding of their symptoms. The BU group has yet to study a control group of similarly aged individuals who did not play an impact sport. We should be careful to take these studies and their results as the last word on CTE and what causes this severe brain disease.
It is important to note that not everyone who suffers repetitive hits to the head will develop CTE. Some scientists believe that risk factors that make development of the disease more likely include length of exposure to head impacts and age of exposure to head impacts, however, no direct links have been made between causes of CTE. When considering the risk factor of length of exposure to head impacts, the Concussion Legacy Foundation states:
“Athletes with longer careers playing contact sports are at greater risk for CTE than athletes with shorter careers. A 2019 study on deceased football players led by Boston University researchers and published in the Annals of Neurology medical journal found that the risk and severity of developing CTE among football players is not correlated to the number of concussions experienced, but is instead correlated to the number of years playing tackle football.
The study analyzed 266 deceased football players, 223 of whom had CTE and 43 of whom did not. The researchers found that the risk of CTE increases by 30 percent every year of tackle football, and doubles every 2.6 additional years. (We don’t know the risk of developing CTE after one year of playing tackle football, but it’s likely very low.) This shockingly strong relationship between years of tackle and risk of CTE may be even stronger than the link between years of smoking and risk of lung cancer.
The link is so profound that a high school football player who starts tackle football at age 5, instead of age 14, has an incredible 10 times the risk of developing the brain disease.”
A discussion with Dr. Willer and John J. Leddy, MD, Clinical Professor of Orthopaedics at the University at Buffalo School of Medicine and Biomedical Sciences and Director of the UB Concussion Management Clinic, reveals that unfortunately, the available research on CTE is missing some important variables.
When making a statement such as, “This shockingly strong relationship between years of tackle and risk of CTE may be even stronger than the link between years of smoking and risk of lung cancer,” a researcher better be as close to 100% sure that the link is truly that strong. At this time, conclusive cause-effect relationships in certain events and the development of CTE do not exist. In the brains studied and found to have CTE, variables we do not know include (1) previous mental health diagnoses, (2) type of equipment used during play, (3) type of concussion protocol followed immediately after the mild TBI; (4) type of concussion protocol followed in the days after the mild TBI; (5) adherence to protocol; and (6) genetic, environmental, or other predispositions the person may have had to develop Tau in the brain. This list is not exhaustive in any way and leaves questions for future research as well as new insight as to how to utilize this research to benefit those who are currently playing.
Other than the fact that CTE cannot be truly diagnosed until after death, there is a lot more headway that needs to be made before we fully understand CTE. There have not been sufficient studies regarding genetics and whether a person could have a genetic predisposition to how their brain recovers (or does not recover) after suffering a blow. We do know that some people who suffer repeat blows to the head develop CTE, while others do not. The “why?” is not fully understood at this point. Furthermore, the severity of mood, behavior, and personality changes after suffering repeat hits to the head need to be researched further. How significant must these changes be to consider if CTE is a factor?
Furthermore, several published studies show that athletes who begin playing contact sports at a younger age are at a greater risk for CTE than those who begin when they are older. These results indicate that exposure to head impacts before age 12 is associated with worse outcomes.
Diagnosing Mild TBI in Children
The Pediatric Glasgow Coma Scale (“PGCS”) is the scale commonly used to assess the severity of head injuries in children who are too young to speak. This is a modified version of the Glasgow Coma Scale (“GCS”), which is a widely used system for quantifying the level of unconsciousness following TBI and is typically used for older children and adults. In the article Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management, the authors conclude, “the evolving anatomy and age-specific properties of the skull, face, brain, and neck muscles make children susceptible for distinctive types of injuries that are not encountered in adults.” The brain of a child absorbs external forces differently than the brain of an adult, due to a combination of higher plasticity and deformity in younger brains.
The GCS is divided into three categories, eye opening (“E”), motor response (“M”), and verbal response (“V”). The modification of this system for PGCS removes the verbal test where some children may be too young to speak. The overall score is determined by the sum of the score in each of the three categories, with a maximum score of 15 and a minimum score of 3. A score of 13-15 indicates mild brain injury, a score of 9-12 indicates moderate brain injury and suggests there was a loss of consciousness for more than 30 minutes, and a score of 3-8 indicates severe brain injury.
Differences Between TBI in Adults and Children
TBI in children can alter the course of brain development because the child’s brain is still developing, as compared to the fully developed adult brain. A National Institutes of Health Project studied over a hundred young people as they grew by scanning the developing brain. This study revealed that even though the brain reaches approximately 90% of its full size by the time a person is six years old, there is a massive reorganization that occurs within the brain between ages 12 and 25.
Studies completed by the University of Virginia Medical School have determined that the development of a brain has a significant effect on the time period of recovery from a TBI – even mild TBI, which we commonly refer to as a concussion. Research suggests that the recovery time of a mature brain is within five to ten days, while the vulnerability of a young brain makes recovery time much longer and can result in long-term difficulties for that individual. In his study with rats, Dr. David Hovda, director of UCLA’s Brain Injury Research Center found that immature animals with a mild head injury took 6 to 10 times longer to recover than mature rats with the same injury. Despite these research results, Barry S. Willer, PhD and John J. Leddy, MD note that the brain of a child typically
Dr. Jeffrey Barth, in his presentation for Brainline.org, states “The brain develops from the bottom up and from the back forward. So the last thing that kicks in is the frontal lobes, and that is the area of judgment.” The results of a TBI on a developing brain can thus be extremely detrimental and can interfere with the continued growth that would normally happen during various stages of life. Yet, with proper concussion protocol and subsequent treatment, children are likely to heal and bounce back even faster than adults.
What We DO NOT Know about TBI in Children and its Effects
Due to the plasticity of a child’s brain, one may argue the brain is less “set” than that of an adult and therefore there is hope the damaged tissue and areas of deficit will be bypassed in the child’s brain by other parts taking over for these areas that no longer work well. However, recent research does not support this conclusion and leads to a belief that because children have a much smaller “bank” of previously learned information to fall back on after a head injury, these vital building blocks for learning are much fewer in children and results in subsequent handicap due to an already lacking foundation of intact information.
Further, the effects of TBI on a child may not be seen directly after injury, whereas these effects are almost immediately noticeable in adults suffering similar TBI. As children are expected to learn and grow cognitively, the effects of TBI may not be seen for months or even years when the child is required to learn, act, or behave in new, mature ways. A major concern comes into play where frequently, problems resulting from TBI are dealt with inappropriately as if they are due to learning disabilities or emotional causes. Misperceptions such as these may devastate the child, because the strategies used to help a child with TBI are different from those used to address similar problems that stem from other causes. A child may suffer in two ways: (1) feeling diminished or confused because no one knows what is really wrong, and (2) being damaged in their ability to learn. Figuring out the cause of certain behavioral and learning deficiencies in young children is vital for proper treatment. Without discovering the root of the issue (in this case TBI), a child’s symptoms can be missed or mistreated for years.
Concerns Regarding Children Under Twelve Participating in Contact Sports
Given the high probability of TBI occurrences in contact sports and the severe, lifelong detrimental effects such injuries can have on children, it has been proposed that young children not be allowed to participate in programs that are likely to lead to occurrences of TBI in children. However, others argue that only 21% of all TBI in children result from contact sports and that on average, the kids “simply are not big or strong enough at that age to cause significant damage to each other.”
The Concussion Legacy Foundation supports legislation banning tackle football for children under twelve years old. The foundation states that 86% of football players studied at the Boston University CTE Center have been diagnosed with CTE, and risk appears to be linked to how many years they played. Further, another Boston University study found athletes who played nine or more years of contact sports were six times more likely to develop Lewy Body Disease, a cause of dementia, than those who played eight or fewer years. Again, these results are offered with caution, as other scientists have not confirmed these results (there are less than a handful of people who orchestrate this research) and there is little information regarding what other diseases may have caused these results and each individual’s predisposition to these diseases.
Legislation proposed in at least five states that would effectively ban children under twelve years of age from playing tackle football has yet to gain much traction. Many parents argue that the decision regarding their child’s participation in athletics is ultimately theirs and should not be dictated by the government. However, at the end of the day, many opposing the proposed legislation have yet to explain why five-year-old children should suit up and sustain hits to the head dozens of times when a no-contact alternative would be just as sufficient a route for children to learn the game. At the same time, before dictating a broad ban of a sport so many love to learn and play, we should remember children tackling at this age are very small and moving at slower speeds and therefore the resulting impact is not nearly as severe as what we typically see on TV during a professional game.