This past Thursday, Boston University CTE Center director Ann McKee presented the specific findings of the brain examination of New England Patriots’ player Aaron Hernandez. Mr. Hernandez was serving a life sentence for murder when he committed suicide in his Massachusetts prison cell. The family donated his brain after his death. At age 27, his brain was determined to have Stage 3 (of 4) chronic traumatic encephalopathy (CTE), with severe deposition of tau protein in the frontal lobes of the brain.
Dr. McKee noted, “These are very unusual findings for someone so young”, stating that this level of damage usually is found in players at least 20 years older. In a 2016 New York Times interview after the death of Oakland Raiders quarterback Ken Stabler, Dr. McKee correlated long careers plus the increasing age of the player with the severity of CTE.
Dr. McKee confined herself to presenting the pathology, but the CTE Center’s research has associated CTE with aggressiveness, explosiveness, impulsivity, depression, memory loss and other cognitive changes. The CTE Center has pioneered research in the prevalence of CTE in NFL players’ brains [TTA 26 July] and is conducting longitudinal research on the relationship between concussive and sub-concussive head trauma and behavioral change [TTA 21 Sept] in the living. More details and video available here: Boston Herald, CNN. The September BU CTE Center diagnosis of Mr. Hernandez.
The importance to health tech is in the prevention, mitigation, and early diagnosis (not possible yet) of the end result of repeated concussive and sub-concussive damage, sustained in contact sports, military service (usually combat), and in civilian trauma from, for instance, car and industrial accidents. TTA’s long-standing coverage of CTE and brain trauma can be gleaned from searches on these terms.
An extension of Boston University’s pioneering CTE brain research [TTA 26 July] is this newly published study in Translational Psychiatry on cognitive and behavioral changes in former football players. This sampled 214 living former American football players who played high school, college or professional football and did not participate in any other organized contact sports. These players were recruited through BU’s LEGEND longitudinal research registry of living active and former contact and non-contact sports athletes to examine the short/long-term outcomes of repetitive head impacts (RHI). Participants in the program performed over time a battery of cognitive and functional tests. It also screened out those who self-reported concussion within one year of the study inception.
The findings point a very long finger at early tackle football playing in youth football programs, typically from age 5 to 14 when the brain is undergoing massive development. Below quotes are direct from the study:
- Those who began playing football before age 12 had >2 × increased odds for clinically meaningful impairments in reported behavioral regulation, apathy and executive function, and >3 × increased odds for clinically elevated depression scores, compared with those who began playing at 12 or older.
- Effects were independent of age, education and duration of football play.
- Younger AFE (age of first exposure-Ed.) to football, in general, corresponded with worse behavioral regulation, depression, apathy and executive function, as well as increased odds for clinical depression and apathy.
To our knowledge, this study is the first to show a relationship between younger AFE to football and reported clinical dysfunction in a cohort that included both former amateur and professional football players. There was no difference in the effect of AFE by highest level of play. These findings validate and expand upon our previous work in a small, entirely distinct sample of former NFL players, and extend the influence of AFE to football on clinical function to former football players who only played through high school or college. Overall, this study provides further evidence that playing youth American football may have long-term clinical implications, including behavioral and mood impairments.
The study has an extensive discussion of brain development in the young and how ages 9-12 are critical. Two studies using helmet accelerometry on current youth American football players estimate 240 to 252 median head impacts per season.
There are a considerable number of caveats throughout the study, including the kind of protection available in past youth football for the average age respondent (51) and the self-reporting methodology. It is not a risk study for CTE, nor is it intended to advocate the reduction or elimination of youth football. It does advocate for more longitudinal studies. This Editor has attended at least two talks by the CTE Center’s Robert Stern, MD, and he has been never been content with limiting his study to either football or to purely concussive damage.
Why is this research important to healthcare and to technology? (I’ll expand upon a previous closing.)
- First, because repetitive brain trauma–concussive and sub-concussive–now has an even better-documented relationship to significant medical and behavioral conditions. This study is now another part of fundamental research to deepen our knowledge about the effects and long term brain outcomes of head trauma, whether from football, other contact sports, combat service (e.g. IED explosions), car accidents, and even repetitive actions by a person who is developmentally disabled.
- Second, avoiding or minimizing head trauma in sports and warfare, plus correctly diagnosing and treating concussion and sub-concussion, are huge areas for technology about which this Editor has advocated for several years.
- The message here is not that football is bad, but in the present state and starting age is played dangerously for long term brain development and the subsequent mental health of players. This does not exclude other high contact sports such as flag football, hockey and rugby–the orthopedist’s gift–and heading the ball in soccer. We need to know more, minimize it now, and both playing the game, with the aid of health tech, should be part of this.
Translational Psychiatry (Nature.com), STATNews has further analysis
Related reading: Our extensive backfile of CTE research coverage is here, including this Editor’s reports on Dr. Stern’s presentations at NYC MedTech and GCRI.
Updated for additional information and analysis at conclusion.
In the largest-ever case study published of CTE–chronic traumatic encephalopathy
—VA Boston Healthcare System (VABHS)
and the Boston University School of Medicine’s CTE Center
found mild to severe CTE pathology in nearly all of the brains of former football players studied. Jesse Mez, MD, BU Medical assistant professor of neurology and lead author on the JAMA study
, said that “The data suggest that there is very likely a relationship between exposure to football and risk of developing [CTE].” The CTE is marked by defective tau (stained red in the brain sample pictures, click to expand), which is also evident in Parkinson’s and Alzheimer’s Disease.
Of the 202 brains donated to the VA-BU-CLF (Concussion Legacy Foundation) Brain Bank:
- The most dramatic finding is the detection of CTE in 110 of 111 donated former NFL players’ brains (defined as having played one play in a regular NFL season game).
- In addition, the brains of other football players were studied. CTE was detected in seven of eight Canadian Football League former players (88 percent), nine of 14 semi-professional players (64 percent), 48 of 53 college players (91 percent), and three of 14 high school players (21 percent).
- The severity increased with length of play, with the majority of former college, semi-professional and professional players having severe pathology. The deceased high school players diagnosed with CTE had mild pathology findings. Age at death ranged from 23 to 89.
- Player position mattered. Linemen, running backs, defensive backs, and linebackers, who take most of the punishment in football, were the bulk of the donated brains with CTE.
Separately, and with no knowledge of the pathology, backgrounds on each donor were compiled to gather medical history and symptoms. What was striking were the personality changes evident with even mild CTE. Dr. Mez: “We found cognitive, mood and behavioral symptoms were very common, even among players with mild CTE tau pathology. This suggests that tau pathology is only the tip of the iceberg and that other pathologies, such as neuroinflammation and axonal damage, contribute to the clinical symptoms.”
Preliminary to the current study was UNITE (more…)
Not shocking to our Readers. In December, sports network ESPN reported that the National Football League (NFL) refused to fund research on detecting in vivo chronic traumatic encephalopathy (CTE) from a long-term $30 million unrestricted grant to the National Institutes of Health (NIH) [TTA 23 Dec 15]. A 91-page report by Democratic members of the House Committee on Energy and Commerce, which started after the December reports, confirmed that the NFL improperly attempted to shape the research after the grant, violating NIH peer-review process policies that stipulated no grantor interference. The NFL specifically objected to the objectivity of Boston University’s Robert Stern, MD heading up the $16 million project before the award in 2015, then tried to redirect the money, so to speak, in-house–to a group including Dr. Richard Ellenbogen, a member of the league’s panel on brain injuries and their bid for the project. Ultimately, the NFL withdrew the funding from the NIH, which went ahead with it. The project was awarded to BU, the Cleveland Clinic, Banner Alzheimer’s Institute (Arizona) and Brigham and Women’s Hospital in Boston.
The Congressional report’s six major conclusions were highly critical of the NFL in several ways and also scored the Foundation for the NIH for not acting as a ‘buffer’:
- The NFL improperly attempted to influence the grant selection process at NIH.
- The NFL’s Head, Neck and Spine Committee members played an inappropriate role in attempting to influence the outcome of the grant selection process.
- The NFL’s rationalization that the Boston University study did not match their request for a longitudinal study is unfounded.
- FNIH (Foundation for the NIH) did not adequately fulfill its role of serving as an intermediary betweenNIH and the NFL.
- NIH leadership maintained the integrity of the science and the grant review process.
- The NFL did not carry out its commitment to respect the science and prioritize health and safety.
When the grants were announced in September 2012 [TTA 7 Sept 12], there was great cheer that finally the NFL had decided that denial was, to use the old joke, a river in Egypt, and to do something about it. This also followed Army research on TBI being supported by the NFL. The first indicator that the funds were going elsewhere, as we noted a year later, was that a year later the Sports and Health Research Program (SHRP) funds were going to other medical problems like joint diseases and sickle cell anemia. While worthy, it had not been the prime publicized objective of the funds. The Congressional committee report also details how the NFL tried to steer the research away from Dr Stern, one of the leading researchers in the field, citing his support of players who refused to accept the CTE settlement in 2014. Beyond the NFL, research on CTE and concussion will impact any contact sports as well as the military and other head traumas. This Editor has previously reported on Dr Stern’s CTE research presentations in NYC and from other researchers in the field; search on NFL and Dr Stern both in current index and the back file. Congressional report, ESPN.com, New York Times.