Ready for some head trauma? What to make of CTE in the NFL news

With the Cincinnati Bengals opening training camp today and playing their first preseason game on August 11, NFL football is so close you can almost hear the bone-crushing hits and whiff the smelling salts rousing players back to consciousness. While much of the focus will be on new players and the upcoming season, it’s difficult to overlook the threat of Chronic Traumatic Encephalopathy (CTE) lingering in the background, especially after the recent flurry of headlines claiming that 99 percent of former NFL players studied showed evidence of CTE.

Before we take a step forward, let’s take a step backward so we can better understand the present culture of brain injuries in the NFL. Since its inception, football has been a rough, physical sport. It’s akin to uncontrollably slamming your body against a brick wall multiple times – and having that wall hit you back. Because of its violent nature, there have been efforts to make the game a little safer for the participants throughout the ages. One such innovation was the advent of head protection, which has gone through quite an evolution during the past 120 years. Initially, head protection was designed just to prevent the undesired “cauliflower ear” and reduce the chances of a player getting his “lights knocked out”, but it has continually progressed.

• 1900’s soft leather harness
• 1910’s soft leather helmet
• 1920’s soft leather helmet with more padding
• 1930’s hard leather helmet
• 1940’s hard leather helmet with graphics and logos
• 1950’s plastic helmet and face bar
• 1970’s plastic helmet and facemask

Back then, these advancements in player protection were considered adequate, and not much though was given to the lingering effects of head trauma. If a player got their “bell rung”, they might get to take a play off, if they were lucky. But unless an injury was a broken bone or torn muscle, players just kept playing. That was the tough-guy culture of football and players proved their “toughness” by not coming off the field for head-related injuries.

But the path to changing the culture of head injuries in football slowly began to change about 15 years ago when Dr. Bennet Omalu discovered evidence of CTE when conducting an autopsy on the brain of former Pittsburgh Steelers player Mike Webster. If the names sound familiar, Will Smith played the role of Dr. Omalu in the recent movie “Concussion”. Three years later, Dr. Omalu’s findings were published in a 2005 issue of Neurosurgery. The NFL’s initial reaction was denial, as their own Mild Traumatic Brain Injury Committee rejected Dr. Omalu’s findings and called for a retraction. In 2006, Dr. Omalu published a second paper, looking at another former NFL player who had been found to have suffered from CTE before committing suicide. CTE is only diagnosable after death, as it requires the study of the brain, which can not be conducted to those who are living. In 2007 the NFL dismissed findings of CTE in various deceased NFL players, and it wasn’t until 2009 the NFL publicly acknowledge a link between football induced concussions and CTE.

Over the past 15 years there have been studies conducted on various former NFL players who were found to have CTE. One of the most famous was Hall of Fame linebacker Junior Seau, who committed suicide. He ended his lengthy career with just under 2,000 NFL tackles, plus countless other hits in games, not to mention hits from practices, preseason play, and his days playing college and high school football. Another prominent case was that of former Kansas City Chiefs player Jovan Belcher, who killed his girlfriend, and then drove to the Chiefs’ facility and committed suicide in front of the Chiefs head coach and general manager.

In the wake of the findings linking concussion to CTE, and seeing the detrimental effects it’s had on former players, a bevy of current players opted for early retirement in fear of facing a possible future with CTE. Just this week, Ravens guard and Ph.D. holder John Urschel announced his retirement from the NFL on the heels of the newest news about CTE. All-Pro linebacker Patrick Willis was previously the most prominent former NFL player to go into early retirement, with Cortland Finnegan, Jake Locker, Jason Worilds, and Chris Borland also joining the initial ranks of players passing on large NFL paychecks in fear of brain injury, including CTE.

The public has watched the NFL go through the five stages of grief in regards to the link between football-induced concussions/hits to the head and CTE. First the NFL displayed Denial, ignoring the medical findings and continuing with their multi-billion-dollar industry as if there were no chinks in the armor. Next, the NFL expressed Anger, and went on the offensive. They publicly discredited Dr. Omalu, and used their own “experts” to reject such connections between football and CTE. Third, the NFL Bargained with the public and its players, paying $765 million in a lawsuit brought by former players. Presumably the NFL has gone through a little Depression as they can’t continue covering up the dirty, little not-so-secret secret that playing the sport of football is very dangerous, and now the league is in the final stage of slowly Accepting the reality of football and CTE, and have implemented their league-wide “concussion protocol” and are sponsoring a program of “Heads Up” football in youth leagues, teaching techniques which ideally, are a little less conducive to concussions and future brain damage.

Years of denial by the NFL in regards to the CTE link has generated a level of distrust between fans and the league on this subject, and the media is always looking for a story to sell. So, it’s no surprise that headlines came out casting a damning light on the NFL with “99 percent of former players suffering from CTE”. And it’s no surprise that many were alarmed by the high rate of CTE among former players. But putting aside our initial bias, what did the study really say, and what did it conclude?

On July 25^th a trio of doctors (Dr. Jesse Mez, Dr. Daniel Daneshvar, and Dr. Patrick Kiernan) published a study “Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football” that looked at the occurrence of CTE among people who played American football. One of the findings was that CTE was found in 110 of 111 former NFL players, which is what fueled the mini media blitz about head injuries and the NFL. But this 110 of 111 statistic is quite misleading, and not as conclusive as one may assume. Here’s why.

The primary reason why the headlines from the study are a bit misleading is that the study was conducted on brains who were suspected, and likely to contain evidence of CTE. The brains studied came from “brain banks” of donated brains of former football players, and many these brains were donated by families who suspected head trauma from their deceased family members. Basically, it would be like looking for sand in the desert, or seeking a priest in the Vatican.

Another reason why a solid conclusion can’t be made from the study is the lack of a control group to compare the group who played American football with. The 99 percent number is a high number, but without a group of non-football playing brains to contrast it to, the risk factor is unknown if it can’t be compared to anything.

CTE was found in 117 of 119 NFL and CFL players, compared to only 3 of 14 people who did not play football past high school. On the surface this gives the impression that the people who played football longer became much more susceptible to CTE. But CTE is a degenerative condition, meaning that it takes a longer time to show up. So a younger person who died would be less likely to show CTE symptoms than an older person who played in the NFL, because the older person had more time for the degenerative symptoms to develop. Also, the older NFL and CFL players studied were playing decades ago when conditions were not as protective as they are for the younger high school players who were studied.

Another consideration is that there are different stages of CTE. Many of the brains studied of former college football players had CTE, but only about half of them had the more severe stages of CTE. This contrasts with the NFL and CFL, where there was severe forms of CTE found in a majority of the brains studied. But was this a direct result of more occurrences of head trauma, or just more time for the progression of degeneration to occur?

These questions, and others, are why the study itself concluded “CTE may be related to prior participation in football.” That’s a very generic, non-committal statement as even the doctors who conducted the study seem to be admitting the study merely showed that some people who played football, and were suspected of having CTE, did actually have CTE. It’s a far cry from the NFL equals CTE headlines and conclusions that the media and public were given.

This study does not, and cannot, make any conclusions linking playing in the NFL with a 99 percent chance of getting CTE. But it should serve as another reminder that football is a dangerous sport, and one filled with activities that can lead to head injuries and future issues with neurological processing. There is still much that needs to be studied and discovered before we know just how dangerous the game is and before we jump to conclusions by misreading headlines out of context. I would encourage anybody else who is interested to read the study, which can be found online via the Journal of the American Medical Association.