Youth football playing may contribute to long-term cognitive, behavioral issues: BU study

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. 

Congressional investigation confirms NFL attempted to influence concussion, CTE research

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’:

  1. The NFL improperly attempted to influence the grant selection process at NIH.
  2. The NFL’s Head, Neck and Spine Committee members played an inappropriate role in attempting to influence the outcome of the grant selection process.
  3. The NFL’s rationalization that the Boston University study did not match their request for a longitudinal study is unfounded.
  4. FNIH (Foundation for the NIH) did not adequately fulfill its role of serving as an intermediary betweenNIH and the NFL.
  5. NIH leadership maintained the integrity of the science and the grant review process.
  6. 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.

Bioidentical, dissolvable brain implants for monitoring injury

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2016/02/1499.jpg” thumb_width=”150″ /]A pressure and temperature sensor which sits on the surface of the brain to monitor intracranial pressure and temperature changes has been developed by an international team from South Korea and the US. Currently, implantable sensors are used for monitoring victims of severe traumatic brain injury (TBI), but these sensors carry risk of inflammation and infection. In initial testing, this new sensor has been found to be fully biocompatible (no inflammation or scarring) and dissolves in a few weeks. It can also be modified in other ways to monitor other brain functions, such as acidity and the motion of fluids, or deliver drugs. Published in Nature. Summary in the Guardian.

 

 

Blood biomarkers to diagnose mild TBI; more studies on TBI, concussion

An abundance of studies pointing the way to digital health opportunity. A surprise on the early morning radio news in NYC was mention of a report on a blood biomarker that could confirm a diagnosis of concussion, published in the Journal of Neurotrauma. Once found, it wasn’t exactly as advertised but the research is worth reviewing. First, it applies to mild TBI. The biomarker is the extensively studied glial fibrillary acidic protein (GFAP) versus another biomarker, S100β. The key finding by the central Florida-based team is that in a general trauma population, GFAP out-performed S100β in detecting intracranial lesions as diagnosed in CT scans. Scrolling down in the article is a link to the abstract of a meta-study of 11 biomarkers in concussion, by the same lead researcher and another team. The current featured articles in Neurotrauma are a stunning review of studies around concussion and TBI, including two very interesting articles on why air evacuation can do more harm than good (unless absolutely necessary) for TBI patients (altitude lowers oxygen levels) and how mild TBI suffered by retired NFL players has long-term negative metabolic and pituitary effects. All paywalled unless you have library access or a friend with subscription access; however some of the citation articles are open access. But for health tech developers looking for problems to solve better, cheaper and faster, here it is–a lot more promising than yet another me-too wearable. 

NIH funds in vivo CTE research with $16 million–$0 from NFL; “Concussion” released

CTE research funded–and at a US theater near you Christmas Day

In the run-up to the holidays, our Readers may have missed another gift to those concerned with brain health–the National Institutes of Health (NIH) awarding of a major grant to fund research on chronic traumatic encephalopathy (CTE) to diagnose victims in vivo (while still alive). Awarded by NIH in conjunction with the National Institute of Neurological Disease and Stroke, the $16 million will go to researchers from Boston University, the Cleveland Clinic, Banner Alzheimer’s Institute (Arizona) and Brigham and Women’s Hospital in Boston. Leading the team is Robert Stern MD, Boston University professor and director of clinical research for BU’s Alzheimer’s disease and CTE centers, and a researcher we’ve followed since his June 2013 presentation at NYC’s German Center. According to a report in sports network ESPN’s ‘Outside the Lines’, the National Football League (NFL) refused to fund this research from their long term $30 million grant to the NIH due to Dr Stern’s alleged lack of objectivity; according to ESPN, a NIH official told ‘Outside the Lines’ that “the NFL’s $30 million gift was contingent on the league being able to veto decisions on projects that the money was funding.” Seemingly outside this research is another area of interest to Dr Stern–why some athletes have CTE, and others do not, as discussed in the May 2014 NYC MedTech ‘Brain Games’ presentation attended by this Editor.  Medical-Net (BU release), New York Times

Sports CTE and brain injury is back on the front pages with the release of the film ‘Concussion’, starring Will Smith as foundational researcher Bennet Omalu MD, the then-Pittsburgh forensic pathologist who uncovered CTE after performing a detailed brain examination of Pittsburgh Steelers center Mike Webster, who died of a heart attack aged 50 in 2002. His 2005 case report with others from University of Pittsburgh in Neurosurgery was the kick-off (so to speak) and so enraged the NFL that they attempted to have it withdrawn from the journal. In this interview with Medscape EIC Eric Topol MD, Dr Omalu discusses (more…)

What’s news at the end of the week

Care Innovations harmonizes seniors, Panasonic adds diabetes, Jawbone and Fitbit bite, the first EHR/PHR Hack and Concussion in Cleveland. Converging its interests in remote patient monitoring with its long-time footprint in senior housing resident monitoring (QuietCare), Intel-GE Care Innovations is testing its Health Harmony remote patient monitoring system, partnering with two California-located Front Porch communities and the Front Porch Center for Innovation and Wellbeing. The residents selected have poor chronic condition management or have returned after a discharge from a skilled nursing facility. No disclosure on projected number or duration–and it doesn’t appear that QuietCare is part of the monitoring. Release….Panasonic just bought Bayer Healthcare’s diabetes/blood glucose monitoring device unit for $1.13 billion as Bayer continues to shed non-life science businesses. While old-school prick-and-bleed monitors are being eclipsed by continuous glucose monitors (CGMs) and mobile-based devices such as Telcare in the US and in Europe, there’s plenty of market remaining in the West, and new ones in Asia and the Middle East for simple devices. It joins Panasonic’s existing blood pressure monitors. MedCityNews….Jawbone and Fitbit continue to snap at each other in court, with the former on Wednesday filing a second lawsuit on patent infringement, specifically “a wellness application using data from a data-capable band”, with the added fillip of going to the International Trade Commission, which could ban the import of Fitbit products or component parts. The 28 May lawsuit was about Fitbit’s hiring of five former Jawbone employees who allegedly stole IP. The companies between them have hundreds of patents, and as this Editor has noted in previous IP and patent troll articles, the US Patent and Trademark Office (USPTO) is not especially rigorous in ensuring that patents are not overbroad. Wonderful for the IP attorneys, but not exactly what Fitbit wants as a runup to their expected IPO next week. Wall Street Journal….Now an EHR and PHR join Hackermania Running Wild. Medical Informatics Engineering reported Tuesday that in May their server was cyberattacked, exposing PHI of patients in five clients and separately information contained in the NoMoreClipboard PHR subsidiary. POLITICO reports that this is the first recorded instance of an EHR compromise. MIE ReleasePOLITICO Morning eHealth….If you are in the Cleveland, Ohio area and have an interest, Concussion: A National Challenge is a free, two-day event on detection and diagnosis sponsored by the National Academy of Engineering, the Institute of Medicine, Case Western Reserve University, Metro Health and Taipei Medical University. Advance registration required.

‘Brain Games’ on preventing, diagnosing sub-concussive brain trauma

Tuesday 13 May, presented at NYC MedTech-the NYC Medical Technology Forum, at Troutman Sanders LLP, Chrysler Building, New York City

In a packed (agenda and attendees) two hour evening meeting, three presenters detailed the latest research on the clinical signs of chronic traumatic encephalopathy (CTE), along with new technologies for detecting it as it happens and diagnosing it plus monitoring recovery: Robert Stern, PhD, professor of neurology and neurosurgery at the Boston University School of Medicine and a leading clinical researcher on CTE (as our long-time readers know) ; Isaiah Kacyvenski, head of the sports segment of electronics designer MC10 which developed the Checklight head impact indicator for Reebok; and Uzma Samadani, MD, PhD, co-founder of Oculogica which presented at ELabNYC a few weeks ago.

Dr. Stern’s presentation reviewed his clinical work with primarily NFL players in how CTE manifests in both behavior patterns and the brain. His focus remains on sub-concussive trauma, the ‘bottom of the iceberg’ in his analogy, and its cumulative, long-term effects.  Repetitive brain trauma–neuronal shearing which is produced by linear, lateral and rotational forces to the head–produce a cascade of brain changes leading to destruction of brain tissues that show as dark patches on post-mortem samples and scans. These differ from Alzheimer’s disease in the abundance of tau protein distributed fairly early in life around the brain’s blood vessels and in the depths of the cortical sulci, where Alzheimer’s signature beta amyloid does not locate. Dr. Stern’s research also incorporates the behavioral changes that precede diagnosis: the emotional ‘short fuse’, the difficulty in memory, accidents, suicide, drastic changes in behavior and impulse control. There are many examples of degeneration and early death among players [TTA 6 Dec 12 which also refers to Dr. Stern’s research published in Brain; also see TTA 5 June 2013 on his German Center presentation which has additional background on his and his team’s research.]

In addition to the work he has done relating to (American) football (he is on the NFL Players Association brain injury committee and his research was instrumental in the PA’s lawsuit against the NFL), he studies other contact sports such as hockey (brain injury clusters (more…)

Concussion diagnostics a hot area

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2014/05/Cerora-Simon.jpg” thumb_width=”150″ /]Diagnosing concussive and sub-concussive head blows both in sports and on the battlefield have been challenging, and your Editors have chronicled several approaches. One of the 2014 graduates of NYCEDC’s ELabNYC was Oculogica; their EyeBox CNS records three key eye movements in a 4 1/2 minute test to determine whether they fit a normal box pattern, with subsequent exams determining rate of brain recovery [TTA 17 Apr]. (We’ll be seeing more of Oculogica at NYC MedTech 13 May, along with MC10 which helped to develop the Checklight impact indicating skullcap with Reebok, seen at last November’s CES preview [TTA 15 Nov 13] and winning CES’ 2014 Design & Engineering award.) Now out of Bethlehem, Pennsylvania is Cerora’s MindReader, developed out of Lehigh University, Ben Franklin Technology Partners of NE Pennsylvania and in the first StartUp Health Academy/GE Entrepreneurship class. It is a wireless dry contact EEG reader which combined with other biosensor data and clinical observation aids speedy diagnosis. The reader is worn either on Google Glass or a headset (pictured above left on CEO Adam J. Simon, PhD). It’s in early days and still in testing; the baselines alone will need data from at minimum tens of thousands of subjects beyond the current testing on Lehigh U. athletes. Dr. Simon is also projecting use for sub-concussion injury, Alzheimer’s, PTSD and other neuropsychiatric disorders. Lehigh Valley Live, release on presentation at the American Academy of Neurology Annual meeting 30 April, WFMZ Ch. 69 News (video)

ELabNYC Pitch Day

10 April, Microsoft HQ, NYC

The Entrepreneurship Lab NYC (ELabNYC) presented its second annual class of companies to nearly 200 life science funders, foundations, pharmaceutical companies, healthcare organizations, universities and the occasional Editor. Of the cohort of 19 companies finishing the three-month program, 56% are now funded and 25% had first customer revenue by the end of the program. Each company pitched for five minutes on its concept, its current state of advancement (including pilots/customers), its team and a funding timeline. This Editor will concentrate on the five companies with a digital health component; she was intrigued by their diversity and focus on difficult problems of compliance and diagnosis, especially dementia and concussion. (more…)

NIH-NFL research grants on brain injury awarded (US)

In September 2012, the National Football League (NFL) donated $30 million to the Foundation for the National Institutes of Health (FNIH) to focus on brain injury. The Sports and Health Research Program (SHRP) now has a somewhat wider scope inclusive of joint diseases, sudden cardiac arrest, sickle cell anemia and hydration/heat injury. Last week they announced eight projects to be supported. Two ($6 million each) are cooperative agreements focusing on brain injury and after multiple concussions. These research projects are:  Boston University, which has pioneered major CTE research [TTA 5 June], and the VA on CTE; the pathology of CTE and delayed TBI from Mount Sinai Hospital in New York City. The six other studies are ‘pilots’ totalling about $2 million over two years and range from cortical GABA in pediatric sports concussion, the Spot Light concussion management app developed by Inlightened, LLC, and eye movement tracking for concussion detection. FNIH release

International CES unveils in NYC

The trends and items of note for next January’s show in Las Vegas

  • The ‘Internet of Things’ is the phrase-du-jour–embedding anything and everything with sensors (digital elements) and blending the physical and digital worlds
  • Consumer Digital Health Care was listed as #3 of CEA’s 2014 Technology Trends to Watch (PDF link). What is hot is self-tracking (1/3 of mobile users have tracked using a smartphone and tablet, and over half are now concerned about data security), integrating tech for seniors (touching on Selfhelp’s Virtual Senior Center [TTA 17 Mar 2010], remote monitoring (telehealth and telecare) including GrandCare Systems and kiosk HealthSpot Station, patient adherence, FDA approval of apps and the home as a healthcare hub.
  • Robots were the #4 trend: consumer robots such as home cleaners Roomba, Ecovacs; robots in eldercare; humanoid robots like NAO; robotic prosthetics and exoskeletons.

Digital health will again be showcased as a TechZone  (more…)

DrChrono and Sermo’s ‘Blue Blazes’ moments

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2013/08/blue-blazes.jpg” thumb_width=”150″ /]Neil Versel in his personal blog Meaningful HIT News notes meaningful lapses in accuracy and good communications taste from two reputable companies targeted to US medical professionals. DrChrono is a mobile ambulatory EHR tweeting about ‘cashing in’ on the HITECH Act–the program that rewards practices for achieving stages of Meaningful Use with EHRs. Sermo is a physician social networking platform that has staged a contest called ‘The Pro Football Injury Challenge’  where one will go ‘head-to-head’ with other doctors in ‘making predictions about how injuries will affect pro athletes this season.’ This Editor felt in her comments below the article that this promotion’s communication crossed the line into, on the usual two-second read, a message that it is OK to ‘play for glory’ and win prizes out of players’ real pain, injury and career disaster–a misbegotten effort to gamify real-world medical situations ostensibly for learning. Yes, both have sound messages at the core, but how they were communicated…regrettable. Both DrChrono and Sermo are nominated for ‘Blue Blazes’ because, to paraphrase Neil, ‘what are their marketers thinking?’ What do you think? And this Editor would be more than open to comments from representatives of these two companies. DrChrono and Sermo, what are you thinking?

Editor’s Update: Sermo has provided an important response and clarification blazingly fast in their blog here. (more…)

Acknowledging the reality of TBI in sports

Last week’s $765 million settlement by the National Football League (NFL) concluded a lawsuit in the works for over a year [TTA 7 Sept 12] that was brought by more than 4,500 players and their families. The more legally minded will argue that the NFL ‘got away with it’ before the season started; they admitted to no causal role between the game and traumatic brain injury (TBI) or chronic traumatic encephalopathy (CTE), which can only be confirmed post-mortem. The financial settlement sets small caps relative to the nature of the illness and the cost of care. What’s Unsettled About The NFL Concussions Settlement (Forbes) Also N.F.L. Agrees to Settle Concussion Suit for $765 Million (New York Times)

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2013/09/nfl-surface.jpeg” thumb_width=”175″ /]If not an admission, player injury response may have been a factor in pushing the NFL into the 21st century. Concussion and injury assessment is a component of ‘Surface on the Sidelines’, part of a $400 million deal announced in May for official NFL adoption of the Microsoft Surface Pro (BusinessWeek). Teams have used iPads in many areas away from the sidelines due to outmoded league regulations, but the New York Giants’ medical/trainer staff used iPads last season to assess player injuries and concussions [TTA 23 Oct 2012]. Surface Pros are now loaded with the X2 app and database which stores player testing and medical history. Team doctors and trainers can now take down information on the field, make assessments and also to administer player self-testing. This allows faster determination of  injury and if needed, to pull the player, although it cannot do what Gizmag‘s headline claims it will: Could Microsoft Surface help the NFL to prevent brain injuries? (photo, SurfaceForums.net) (more…)

Cleveland Clinic concussion diagnostic app repurposed

Perhaps seeing a ‘job to be done’  in diagnosing sports concussions in rural areas where direct medical help can be distant, the Cleveland Clinic is now extending the usage of its Concussion Assessment System (C3) to assessing student athletes after suspect head blows. The two-year-old iPad app can be strapped on to the back of the athlete to measure movements that indicate balance problems, and assesses cognitive and motor impairment; information processing ability; attention/memory; balance and visual acuity. (more…)

Quantifying concussion and sub-concussion

A short and graphical article on the impact of concussions in contact sports. The HealthWorks Collective article unfortunately only focuses on concussion when there’s mounting evidence that cumulative sub-concussive blows at 15-20Gs are just as harmful as concussions at 100Gs [TTA 5 June] and a cause of CTE (chronic traumatic encephalopathy). Hard hits in US football can go up to a stunning 150Gs.The main article is from Popular Mechanics which also describes how equipment, including shoulder pads, are being designed to distribute and detect impact. What’s also surprising is how many Gs normal activities such as hopping off a (high?) step (8.1G) and sneezing (2.9G) can be.

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