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Concussions and Chronic Traumatic Encephalopathy

2015-12-27

There is nothing new about the observation that people who have repeated concussions eventually develop brain damage, altered personalities, mood changes, and mental deterioration.  This is encapsulated in the word “punch-drunk.”  What is new is that the National Football League (NFL) has seen its financial viability threatened by the repeated diagnoses of chronic traumatic encephalopathy in some of its most colorful and high-salaried players.

The NFL’s response to this potential threat has been inconsistent, beginning with denial and attempts to marginalize the first pathologist who published these diagnoses: Dr. Bennet Omalu.  The diagnostic process and the league’s reaction has been dramatized in a movie, Concussion, with Will Smith in the lead role.  Mr. Smith is well-practiced in this role, having done a realistic and appealing portrayal of a fictional doctor who diagnoses and treats a fictional epidemic of vampirism in New York City.  That movie was a remake of the Charlton Heston classic, The Omega Man, and was titled after the original book: I am Legend.  The Charlton Heston movie was actually the second adaptation of the book written by Richard Matheson, the first being The Last Man on Earth, with Vincent Price in the title role.

This post is not about Concussion, which I haven’t seen yet.  It is about chronic (post)traumatic encephalopathy (CTE) and football.  By the time Junior Seau killed himself with a shot to the chest, the problem was well known to football players, and Junior himself thought that he might have it.  He didn’t specifically request that his brain be studied, but considering the method he used to kill himself, it is likely that he did want that to be done.

ESPN published an article about the struggle over Junior Seau’s brain in 2013, entitled  Mind Control.  By the time of Junior’s death on May 2, 2012, the NFL had designated Boston University (BU) as the site for CTE research that it would support.  However, several researchers and medical examiners were involved in the work, and an unseemly competition developed between the separate researchers over possession and control of the brain tissue.  Junior’s family members were approached more than once by different people requesting permission to take Junior’s brain tissue for study.

The National Institutes of Health was designated as the recipient organization.  The NFL had a large part in that final decision, having disbanded its original concussion committee and forming a new committee.  The NFL’s original stance has been radically changed, an improvement over a policy that the ESPN article described in this way:

The players charge that the league’s original concussion committee, which was disbanded in 2009, conducted fraudulent research to hide the connection between football and brain damage. That 15 years of research has been largely discarded, even by the league.

Dr. Rich Ellenbogen is the new committee’s co-chairman.  The ESPN article states that although the NFL had designated BU as its “brain bank” there were complaints that BU had refused to share its tissue samples with other researchers.  Because of these complaints, Ellenbogen and the committee had already tried to steer tissue from the brain of former Chicago Bears safety Dave Duerson to the NIH (unsuccessfully.)  In the Seau case, the article describes Ellenbogen’s reasoning:

Asked in an interview why they suggested the NIH, Ellenbogen said, “We had been talking about it for a while. My point, for a long time I’ve been saying … if you’ve got a problem you want to solve, do you put one university on it or have multiple studies done? The federal government is very good, in some ways, really good about doing this. They don’t have an agenda.”

When they received Junior Seau’s brain, the NIH decided to direct samples to five different research institutions, including BU.  This approach ensured immediate replication of the findings by independent groups, none of whom knew at the time the source or name of the deceased.  The final diagnosis was no surprise given Junior’s symptoms, but it gave vastly more weight to the finding of CTE to have several independent groups all come to the same conclusion.  By contrast, a single diagnosis from BU would have been “just one more brain” since they had already made so many diagnoses in former football players.

Four months after Junior Seau’s autopsy, the NFL donated $30 million to the NIH, an “unrestricted” grant that was the largest it had ever given at that time.

Tyler Seau, Junior’s son, got no “closure” from the diagnosis of CTE.  In some ways, it made him feel even worse.  He had been stressed beyond his limit by his father’s erratic behavior; he was then contacted at a particularly sensitive time after his father’s death for the necessary procedure of obtaining the family’s consent for examination of his brain; and now, with the diagnosis, he realized that, if he had known before his father’s death what was happening to him, he could at least have had an understanding of what was going on, even if the condition was untreatable.

The NFL attempted to direct Junior Seau’s brain away from researchers who had previously made CTE diagnoses and threatened its livelihood: first, away from Dr. Omalu (by having Dr. Chao, Junior’s team physician, bad-mouth Omalu to Tyler Seau), and second, away from BU, which had made so many CTE diagnoses.  The end result was the best from a scientific point of view, although to the NFL, it was no help and may have been even worse because it was independently confirmed by disinterested parties.

The NFL settled the player’s lawsuit in April 2015, offering a projected $1 billion in compensation for head injuries after it agreed to remove the $765 million cap in August 2014.  Some parties immediately filed an appeal of the settlement.  Others have opted out of the settlement process in advance.  Arguments about the fairness or unfairness of the settlement continue, and it won’t be finalized until at least early 2016.

New data from PBS’ Frontline and BU were released in September, showing that of 91 former football players who donated their brains for study after death, 87 had signs of CTE.  This is not a random sample, as it is likely that players who suspected they had CTE would donate their brains for study.  Nonetheless, it is disturbing to see that so many had the condition, because it suggests that many, or possibly even most, football players have a least some degree of CTE.  No further enhancement is likely to occur until a method for diagnosing CTE prior to death is developed.  See this International Business Times article for more about the Frontline study.

Junior Seau’s symptoms were the most important problem, and this problem should be emphasized to all; a definite diagnosis is not necessary to be on one’s guard.  First, he lost what control he had had over his anger and violent tendencies.  Second, he became erratic and prone to mood swings from depression to elation and irritability.  Third, he became inattentive to details that he had formerly taken care to arrange to his satisfaction.  Another symptom that is not universal but frequent was his uncontrolled gambling and sexual behavior.  He also was involved in a car crash in 2010 that some believe was a suicide attempt.

The development of these symptoms, particularly personality changes, is a sign of early CTE.  People who have symptoms like these should be examined and considered for the diagnosis.  Once CTE is suspected, it is possible to control the damage to a person’s life and the lives of his family by placing him under observation and using legal means to prevent him from spending all his money or signing contracts that are damaging to him.  His driver’s license can be taken away; while this does not prevent him from driving, it may reduce the possibility of car crashes.

Some of the behavioral symptoms of CTE may be controlled through the sparing use of what are called “neuroleptic” drugs.  This is a controversial practice; the use of drugs to keep patients docile in the nursing home has been shown to reduce their life expectancy, and it is unlikely that the drugs relieve any of the symptoms internally.  They only prevent a patient from thinking and planning complex, dangerous behaviors, in my opinion.  They likely do not make the patient feel any better.

Thus, the diagnosis of CTE is somewhat like the diagnosis of Alzheimer’s disease.  There is no cure, not even any partially effective treatment.  There are only custodial measures to limit the damaging effects of the patient’s behavior.  Despite this, the advantages of identifying patients who have CTE are significant: the family can know what to expect and be alert to prevent some of the traumatic behaviors.

There was a curious case that occurred a year ago that has some bearing on the age of development of symptoms of CTE.  A 22 year old football player and wrestler with a history of unreported concussions killed himself just before Christmas of 2014.  An autopsy showed that he “did not have CTE” but evidence of prior concussions was found.  The young man texted his mother just before he died: “I am sorry if I am an embarrassment but these concussions have my head all fucked up,” the text said.  It is possible that “chronic traumatic encephalopathy” as a tissue diagnosis takes a lot longer to develop than the symptoms of post-concussive encephalopathy.

Further research may identify treatment, but in the meantime, prevention is the only effective approach.  This is where the NFL comes in.  We can understand their complaint that no-one knows what the incidence of CTE is, that is, how frequently it occurs in people exposed to concussions.  This does not excuse the organization from trying to reduce concussions and reduce the forces to which the brain is subjected during the game of football.

At the same time, the way football is played and who plays it have to be changed.  Small children to college players should not be subjected to full-contact head-butting without making it clear  to the parents and the players that there is a significant risk.  Football is not alone in facing this problem.  Soccer is also the scene of serious head injuries and less obvious concussions.  There is little reason for having soccer players wear helmets, but precautions such as increasing time off after a concussion are warranted.

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