Scientists are learning more and more about the relationship between neurological diseases and head trauma. Dr. Robert Stern a Professor of Neurology and Neurosurgery at Boston University and a lead researcher on CTE explains more about what is known, what isn't, and what's next...
Gaining perspective isn't easy, especially when someone is on the outside of a subject looking in. So much of what and how we decide on different things is based on information gained at arms reach or more; a comfortable distance from point to point contact. It gets uncomfortable at times, especially when a subject starts to hit close to home. The desire to turn away - to avoid thoughts or acceptance - is human; very human indeed.
Morals grow from a very personal analysis of right and wrong; good and bad. We observe, we listen, we read, then allot "X" amount of time to consider before logging something away in our "This is what I know" files, deep in our hearts and minds. But every now and then, a subject comes up that needs to fight through what we hold as common.
I'm a sports fan. I love the game of football in all it's raucous forms. It's a tough, oft times violent sport, and it carries a cost; a bill to be paid by its participants we as fans hear and read about only when a key player goes down. Holding our collective breaths as a player lies immobile on the field of play, some offer up a quick prayer. The hushed whispers of the crowd blend into an ocean-like sound, and as the cart carrying the player disappears, it's washed away as the referee signals to resume play. There are knee injuries, and assorted arms, fingers and toes getting bent in ways they aren't supposed too. It's a tough game. Then there are the collisions on the field that seem to ripple through the crowd. Pads and helmets come together with the crack of a rifle shot, followed by tens of thousands of "Ooooos" coming from the crowd. Most players shake off the the momentary fog that addles their minds. Some trot off the field as they signal to their sidelines they need to take a break. When they come back in to play, the page is turned, the game goes on...
Fast forward to a point in a player's life after he leaves the game of football. Some - not all - experience headaches, trouble sleeping, slurred speech and a variety of other little quirky titches their friends and family pass off for the most part, mostly because they come on slowly, over time. Depression may make an appearance, but in the "Type A" personalities most athletes possess, it's something they don't talk about... It's weakness, right? The life of a professional athlete carries with it a suit of personality armor they wear and utilize while they're playing, and long after they retire from the game they love. Some players made piles and piles of cash while they played in the NFL, while others have only the lore of their time in the professional ranks to see them through as life's time clock winds down. They hold onto to the mystique of being a former NFL player as long as they can, and quietly enjoy the sideways glances sent their way after walking into a restaurant or bar: "See that guy? He played for..." Few notice the limp he tries to hide, and those who hear him slur his words discount it to drink, and not his life long dream.
It's a tough game. Pads and helmets come together with the crack of a rifle shot.
I recently read an article by Paul Voosen. He wrote a piece about former players taking part in a study of the condition: Chronic Trauma Encephalopathy, or "CTE". The article is worthy of notice and your time. Most sports fans have seen CTE many times, but they've consigned the condition to prize fighters. It could only happen to someone who's been punched in the head a few hundred thousand times, right? The misconception held until athletes in other sports began to show similar symptoms. Former NFL players and their families began to ask doctors and the NFL for help. While the medical world began to draw circumstantial lines to football and other contact sports, the NFL began to make changes in equipment, as well as the rules of the game. Former players began to gather in a class action lawsuit, challenging the NFL and its team owners to explain what they knew - or didn't know - about the game they'd made billions of dollars from for the better part of a century. Next up, the lawyers and media take over, and begin to espouse - in the most uncertain terms - that they're certainly-certain about this or that... Really?
Voosen's article inspired me to reach out to one of the premier researcher in the field: Dr. Robert Stern, PhD. He's a Professor of Neurology and Neurosurgery; a lead investigator at the Center for the Study of Traumatic Encephalopathy, and Director, Clinical Core, Boston University Alzheimer's Disease Center. Here's a small slice from Dr. Stern's "about me" page at The Boston University School of Medicine:
"A major focus of his research involves the long-term effects of repetitive brain trauma in athletes and the military, including chronic traumatic encephalopathy (CTE). He recently received a grant from NIH to fund his work on developing methods of detecting and diagnosing CTE during life; this was the first grant for CTE ever funded by NIH (co-funded by the National Institute of Neurological Disorders and Stroke, the National Institute on Aging, and the National Institute of Child Health and Human Development). Dr. Stern oversees all aspects of clinical research at the CSTE, including the Brain Donation Registry, the LEGEND study and the DETECT study
In a phone interview, I mentioned to Dr. Stern about reading the piece by Paul Voosen on brain trauma, and how I found the article fascinating . Then I asked him to give me a rundown on the nature of his CTE study.
Dr. Stern: "We've all been hearing about the long term consequences of repetitive brain trauma for a few years now... Most of that is known or described through the post-mortem examinations of brains of former players... Those examinations have shown the disease called Chronic Traumatic Encephalopothy (CTE). CTE is a neuro-degenerative disease that is similar to Alzheimers and other brain diseases. But it's a unique disease that has a history of repetitive brain trauma; meaning that every case of CTE that has been diagnosed after death, has had a history of repetitive brain trauma at some point in their life. No case of CTE has been diagnosed without that kind of history. So that leads us to surmise that some sort of repetitive brain trauma is a necessary variable for the development of CTE, but it's not a sufficient variable.
"There's a lot of people out there who hit their heads a lot, and never get this disease. So there's a few things that come up: One is... We can't figure out who gets the disease and why. What are the risk factors for CTE at this point?
"We can't figure out how common it is at this point, and how to treat it or prevent it at this point...and there's one real reason for all of that, and that is because we can't diagnose it well during life.
"Until we can diagnose it accurately and adequately during life, we won't be able to understand those important issues, like how common is CTE? What are the other causes of it, and how can we prevent it and treat it?"
It's a unique disease that has a history of repetitive brain trauma.
This floored me. The idea CTE can't be effectively diagnosed while a person is alive caused any number of thoughts to flash through my mind. Not truly knowing what's wrong has to take a toll on a player who's experiencing symptoms he doesn't understand. If his hand starts to shake, does he have CTE, or merely some minor nerve damage from another injury suffered years ago? What's more, though there seems to be ample circumstantial evidence to tie CTE to contact sports, the lack of ability currently to identify who actually has CTE and who doesn't, is going to have a huge effect on the 4000-plus players' lawsuit against the NFL.
So this (CTE) isn't something that happens by a single event?
Dr. Stern: "As far as we know, it is not caused by a single big trauma. It seems to be associated with total exposure to brain trauma, including all those sub-concussive hits; that for example, a lineman might, 1000- 1500 times a season, get their heads hit with a G-force (per event) of 20g to 25g. Which - each time - is the equivalent of driving a car, at 30 miles per hour, into a brick wall. Each one of those hits at the line doesn't necessarily result in symptoms. In other words, they can't be diagnosed with a concussion, because they're having no problems, but their brains are getting rattled nonetheless. And it seems that, some people are prone to developing CTE after having a lot of that kind of exposure to multiple hits to the head."
We can't figure out who gets the disease and why.
CTE is about the sustained exposure to brain jarring hits. It's odd, but the football fan in me wonders if there's a higher proportion of players on defense or offense who suffer from CTE? Is it the person who initiates the contact, or the recipient who's more at risk? I'm leaning toward the guy on the receiving end, and the new NFL rule regarding running backs not being able to lower their heads may signal the league feels the same way.
Dr. Stern's comment reminds me too, that brain jarring hits aren't limited to two players colliding from a distance, like a defensive back running full speed to tackle a running back. Linemen are only a yard apart in most cases, and launch themselves forward at each other like 300+ lbs round house punches. The snap counts - the number of plays an individual player takes part in in a game - are virtual countdowns; determining how much a player is exposing himself to potential brain damage.
Interesting, I mentioned something to you about shock trauma, and that concussions don't just happen with head to head hits. A good example is a small running back who gets hit in the chest by a 250 pound linebacker, and is stopped (suddenly); like the car crash analogy you just used. The brain rattles around...
Dr. Stern: "Right, you don't need to hit your head in a helmet to helmet kind of thing... Your brain is the consistency of hard jello, and surrounded by fluid., which is surrounded by the hard, rock-like skull. What happens, when your body gets jolted, or gets hit, the brain can move around inside that fluid and it doesn't have anywhere to go. With adequate types of hits, the brain can become temporarily injured, meaning the inside parts of the brain get stretched and pulled and they are for all intents and purpose injured. You don't necessarily have a permanent brain injury that's caused, it's more of a temporary alteration in the function of the brain cells.
"That's really the definition of a concussion, when your body or head gets hit, and your brain moves around and you have all the variety of concussion symptoms. But there are people who have there heads or their bodies hit over and over again, who don't have the big symptoms of concussion, and that's what we refer to as sub-concussive trauma. So with CTE, it's the accumulation of concussions, and the big hits, but also the repetitive hits that don't have symptoms with it, that can set in motion this neuro-degenerative disease."
The vast majority of NFL players have been playing the game of football for most of their lives. From backyard games, Pop Warner, high school, and college before heading to the NFL, these football players have taken blows to the head across the broad spectrum of the body's growth and development. The question beckons - "At what point did hits to the head cross the CTE line?" Without an index point - when a healthy brain turns from being able to recover from a blow, to sliding toward CTE - it's going to be tough to find a potential answer to making the game of football safer. If I'm understanding Dr. Stern correctly, not everyone who takes numerous blows to the head suffers from CTE later in life. His quest to find what the variable is between CTE sufferers, and those who don't seem to be effected by career long contact, will be the Holy Grail of his study.
Let me ask you a quick question... Is the amount of brain fluid (from one person to the next) consistent? In other words, are some people born with a lot, or...
Dr. Stern: "No, it's pretty consistent."
OK, I thought maybe it was something (that could be checked)... Someone could say you don't have enough of this fluid, so maybe you shouldn't play contact sports?
Dr. Stern: "That's an interesting thought, but no, it's not an issue at all."
And the viscosity of this fluid is consistent?
Dr. Stern: "It's not viscous at all. It's like clear water... So getting to the Voosen article, the goal of the study is to diagnose CTE while people are alive, instead of waiting till they die.. This is a study funded by the N.I.H.; it's the first study of its kind ever funded by the N.I.H... In summary, it's 100 former NFL players - between the ages of 40 and 69 - who come to Boston for a two day evaluation. Then another 50 non-contact sport athletes who come to Boston for the same kind of examination. The examinations include various brain scans, spinal taps, E.E.Gs, cognitive assessments, Psychological assessments and neurological evaluations."
How many of the 100 former players participating in the study are a part of the lawsuit with the NFL?
Dr. Stern: "That's a good question... There's a lot of people out participating in the lawsuit. It's something like 4000 cases... I don't know exactly what number, or what percentage of people (in the study) are also participating in the lawsuit. It's not really an issue for me..."
I hope Dr. Stern forgives my neophyte pondering-s. It's tough at times to separate the sports writer from the fan in me. There isn't going to be a "MacGyver-esk" fix to the problems leading a player to CTE. I hope the research subject pool gets expanded. The 100 former NFL players in the study is a small cross section of the thousands of former players who are still alive and potentially at risk. I hope you'll all drop a quick e-mail on your Congressmen and Senators about funding too.
This study isn't just NFL fan-centric. What Dr. Stern is doing can have far reaching implications on a variety of brain diseases. Whether maudlin or morbid, the NFL players in the study are taking the field once again. They're all on the same team, and are in the fight to find a cure for not just CTE, but Alzheimer's and other conditions. This isn't about a lawsuit, it's about a quality - and sustainability - of life for thousands, if not millions of people.
There's a lot in the news about steroid use, P.E.D.s... Do they contribute to...(CTE)
Dr. Stern:"As far as we know, steroids and other performance enhancing drugs do not contribute to the development of CTE, but it's definitely something we're trying to study."
How strong is the connection between CTE and suicide?
Dr. Stern:"Well, suicides in the NFL have gotten a lot of press. Unfortunately, what happens is that everyone gets really frightened, and it makes a big splash in the media. The message that I want to get out to people, is that a history of having your head hit in sports or other activities and having symptoms of depression does not mean you have CTE; and that depression can be treated and and it's really important for people to seek help."
This may be the single most important subject we've covered in this interview from a media stand point. First, Dr. Stern says quite clearly that the relationship between CTE and the act of suicide aren't directly tied to one another. While depression is a symptom within the description of CTE, it's also presents in other brain diseases. It can be treated, while many other aspects of CTE are without therapeutic recourse. The sad fact is, when people retire from their life long jobs - any job - there's a period of adjustment to career afterlife. Take a look at the chart below.
Depression is not an uncommon condition. You don't have to have CTE to have the symptoms of depression. The key is for anyone who feels they may be experiencing the condition to seek help; reach out to family and friends. I was deeply saddened when former NFL star linebacker Junior Seau took his own life. That a post-mortem showed he had signs of CTE in his brain really isn't the issue though. The depression that led to his death was treatable. But the "Type A" personality I mentioned earlier can be a heavy cross to bare. I don't know what went through Seau's mind before he took his own life. Yet, for him to feel he was beyond being helped bodes a serious question about how successful athletes handle both ego, and how they believe they're perceived by the public at large after they retire.
Suicide isn't a symptom of CTE, period.
Is CTE a repairable condition? Are you on the road to (a cure)?
Dr. Stern: "Unfortunately, CTE, like other neuro-degenerative diseases, is not repairable. So the goal would be to try and detect it early, and try to figure out ways of slowing down the disease. Right now, we have so much work to do. Science is in its infancy. The first step is finding out who has it, and who doesn't, so we can then do some clinical trails of various types of medications to try to slow it down."
We have to wrap our collective heads around the idea of CTE being a disease. It wasn't long ago that being diagnosed being H.I.V. positive was virtually a death sentence. The myriad forms of cancer are slowly falling to medical science, with mortality rates from the disease shrinking year by year. Alzheimer's, and CTE, are getting attention in the medical world like never before. Dr. Stern's research is hell bent on finding a pathway to identifying the how CTE happens, and making it manageable. The key here is being able to differentiate between brain diseases while a patient is alive.
I left this one for last, hoping you wouldn't think me a crack pot... (he chuckles) I tried to go out and look for similar diseases, like Alzheimer's, ect... Maybe I bonked my head too many times, and that's why I'm a writer... (He laughs) How do you differentiate between Alzheimer's, these other brain diseases and CTE?
Dr. Stern: "That's actually a superb question.... Right now, the only way to differentiate between those diseases is to wait until people die and examine their brain tissue. We're getting to the point where we can have a much better understanding of the difference between diseases while people are still alive. It's not 100%, but it's getting a lot better. So what I'm trying to do with CTE, is to use a variety of these types tests to see if we can distinguish CTE from Alzheimer's."
As mentioned, it's currently not possible to definitively diagnose CTE in a living patient. The added problem are the numerous brain diseases with similar symptom lists. How do you treat someone for Alzheimer's, when they're actually suffering from brain trauma caused by numerous concussions? The ability to separate these diseases from one another is crucial to finding an effective treatment.
Is there ever going to be a helmet that's going to make it so players can't be concussed?
Dr. Stern: "Nope. You have to understand there are helmets out there now being used that have better mechanics in them to absorb more of the force, and does a much better job than the older helmets.
"But the brain is still going to move inside that fluid, inside that skull. No matter the helmet that's around it, if the head gets hit and moves quickly, or the body gets hit and moves quickly, the brain is also going to move.
"They can't protect the brain from all hits, at all times."
CTE is about some immutable laws of physics being applied to how the brain can be effected. The main thing people have to understand is, just because you wrap the outside of someone in heavy protection, there are inner-body organs which aren't really all that protected from G-forces. It isn't just the brain that keeps moving after a sudden, violent stop.
The human body is a remarkable collection of specific organic machines. Connected by muscle sinew, tendons, blood vessels and the like, they can all move around a bit. In a jarring stop, organs can move. They can bounce off of hard bone, just as the brain encounters the skull when severely jarred.
Current helmet technology does reduce a number of concussion factors, but it can't stop the brain from sloshing around.
The CTE debate is really in its infancy. The NFL lawsuit regarding former players isn't going away any time soon, and based on what I've learned, the medical science to prove the plaintiff's case just isn't there. How do you go to a jury and say your client suffers from CTE, when it's not possible to prove in a living person? There's a very real possibility this entire case could last for decades, with the players' heirs being the beneficiaries of any monetary judgement. In the near future, the NFL will add former players who suffer from CTE symptoms to their post career medical support system. They don't do enough for the players who've made the league and its owners billions of dollars, but as long as the players don't go quietly into that good night, the NFL will need to deal with them.
If you've been reading this article with an eye toward the possible demise of football, think again. This is just my opinion, but freedom of choice will always win out, and rightly so. We all regularly do things which can cause us harm, and we read about this or that daily that'll cause cancer, heart disease, restless leg and the like. We drive cars too fast, bungee jump off of cliffs, and even - Gulp! - write sports articles...
CTE is a mountain that must be climbed, and Dr. Robert Stern is leading the way. Hand over hand, patient after patient, this disease will find it's manageable end. My greatest hope, is the research Dr. Stern is doing will lead to conquering diseases like Alzheimer's too. How great would it be, for our football heroes of the past to be the source of the biggest win of all?
Photos via USA TODAY Sports