Brain Damage in Football Players

Researchers at Boston University have done an autopsy on another former football player and found evidence of severe neurological damage that would likely lead to dementia later in life:

Leading medical experts at the Center for the Study of Traumatic Encephalopathy (CSTE) at Boston University School of Medicine (BUSM) reported today that nine-year NFL veteran, former Tampa Bay Buccaneer Tom McHale was suffering from chronic traumatic encephalopathy (CTE), a degenerative brain disease caused by head trauma, when he died in 2008 at the age of 45.

In addition, the CSTE has discovered early evidence of CTE in the youngest case to date, a recently deceased 18-year-old boy who suffered multiple concussions in high school football.

McHale, a Cornell University graduate, former restaurateur, husband and father of three boys, is the sixth former NFL player to be diagnosed post-mortem with CTE since 2002. CTE, a progressive neurodegenerative disease caused by repetitive trauma to the brain, is characterized by the build-up of a toxic protein called tau in the form of neurofibrillary tangles (NFTs) and neuropil threads (NTs) throughout the brain. The abnormal protein initially impairs the normal functioning of the brain and eventually kills brain cells. Early on, CTE sufferers may display clinical symptoms such as memory impairment, emotional instability, erratic behavior, depression and problems with impulse control. However, CTE eventually progresses to full-blown dementia. McHale died due to a drug overdose after a multi-year battle with addiction. Expert consensus is that drug abuse of any kind would never cause the neuropathological findings of CTE seen in McHale.

Even though these players are not presenting with symptoms of dementia until much later in life, these findings are disturbing -- particularly in an 18-year-old! Neurofibrillary tangles are one of the two key pathological findings in the brains of Alzheimer's patients. They have no business being in the brains of a 45-year-old and particularly not in the brain of an 18-year-old.

This is a disease that we have seen before -- also called dementia pugilistica -- but before it was limited mostly to old boxers. I guess on some level we shouldn't be that surprised that it also shows up in football players. You can repeatedly collide with another person the size of The Fridge -- sending your brain careening into the side of your skull -- and expect everything to be hunky-dory. (A medical aside: concussive trauma often does double damage because of injuries caused on the side of the brain where it initially collides AND the recoil back to the other side of the skull.)

The real question here is: what is the prevalence of this disease among football players and how much head trauma is necessary before you become at risk? To be entirely honest, we have no good answers to these questions. The problem with many of the studies done to date is that they were confounded by drug abuse or dementia due to other causes. This is why I am really glad to see that other football players have agreed to donate their brain upon their deaths for further research into the subject. We really need to get some sort of number of the concussion you can get before serious problems develop.

I know that there are a lot of parents out there who are wondering what they should do. Unfortunately, I can make two substantive comments on this. The first is that junior and even high school football are probably not dangerous so long as we are very, very vigilant to repeated head trauma. It would really surprise me if the case of the 18-year-old was a common occurrence. Second, if your kid is playing football, make sure that your league has clear policy for head trauma evaluation on the field and clear guidelines for when a player will be taken out of the game -- and out of the sport.

None of these guidelines are complete. At present the guidelines issued by the American Academy of Neurology deal exclusively with acute injury. They don't say anything about repeated trauma. But it is all we have to go on at the moment. Here are the guidelines as they exist now:

The ANN guidelines divide concussion into three levels: Grade 1, which involves no loss of consciousness, with symptoms resolved in less than 15 minutes; Grade 2, with no loss of consciousness and symptoms lasting more than 15 minutes; and Grade 3, causing a loss of consciousness for any period of time. An athlete who suffers a Grade 1 concussion can return to play. However, if another Grade 1 concussion occurs in the same contest, he or she should be taken out of the game.

Someone who suffers a Grade 2 concussion should not be allowed to re-enter the contest and should be monitored to make sure further complications do not arise. He or she should not be allowed to return to practice until symptom-free for a week.

Anyone who suffers a Grade 3 concussion should be taken to an emergency room and receive a thorough neurological exam. An athlete who is unconscious briefly -- for several seconds -- should not be allowed to return to practice for a minimum of one week after the symptoms clear. One who suffers prolonged unconsciousness should be kept out of practice for a minimum of two weeks after the symptoms clear.

The problem with these guidelines is that we really have no prospective studies to show that they work. They were generated by neurologists and neurosurgeons with clinical experience with head trauma, not from studies of cohorts of kids looking at outcomes. Further, they don't really say anything about whether, after the fourth concussion, your kid should never play football again. I don't have good answers to these questions, but this is the field as it exists now.

If I had a kid and he wanted to play football, would I let him? That's another tough question. I would definitely let them play peewee football, and I would probably be OK with high school. However, if they ever got a single concussion, we would need to have a long chat about whether they could continue. I remain skeptical that there is any way to make these sports entirely safe, particularly at the professional level.