I’m a doctor and former wide receiver. My brother’s in the NFL. Chronic traumatic encephalopathy (CTE) is on my mind.
I’m settled into a desk chair with my coffee, fueling up for another day of Zoom medical school, broadcast live to my New York City apartment. The bloc we’re on now—neurology—is a doozy. Well, truthfully, they’re all doozies.
Today’s lecture topic: traumatic brain injury.
The fourth lecture slide includes a picture of Mike Webster, the former Pittsburgh Steeler whose story was made famous by the 2015 film Concussion—starring Will Smith as the physician who discovers the explosive link between football and a neurodegenerative disease found in athletes and others with a history of brain trauma called chronic traumatic encephalopathy—or CTE.
I know what’s coming. It’s not often you get a football reference during a med school lecture. The next few slides outline the consequences of repetitive head trauma. Here it comes. CTE.
My classmates are aware I’m an ex-football player. I get a direct message from one of them: “Knowing what you know now, would you play again?”
It’s not the first time I’ve been asked. I’d asked myself that same question a long time ago.
Football is deeply ingrained in my family. My father and both grandfathers played in college. Justin, my younger brother, is the starting quarterback for the Los Angeles Chargers. My youngest brother, Patrick, is a freshman tight end at the University of Oregon.
I played 11 years of football, four of them as a starting wide receiver at Montana State University. During all that time, I never had a diagnosed concussion. That isn’t to say I haven’t had my fair share of violent collisions.
After my career at MSU, I had an opportunity to attend an NFL team’s rookie mini-camp—basically a tryout for undrafted players. I declined for a few reasons. I knew I wasn’t cut out to be an NFL wide receiver. I also wanted to start the long journey to become a doctor.
My brain health wasn’t a factor in that decision.
Tracing the timeline of CTE discovery
The first link between football and CTE was unearthed in 2005 by Bennet Omalu, M.D., a neuropathologist who’d examined the brain of former Steeler and NFL Hall of Famer Mike Webster while working in a coroner’s office in Pittsburgh.
“Iron Mike,” as he was known, played in 220 NFL football games. The most of any player in Steelers’ history. He’d suffered repeated head trauma during his career.
Webster’s symptoms are now characteristic of repetitive head trauma: memory loss, behavioral and mood changes, cognitive impairment, and dementia.
The underlying process in the brain tissue is an accumulation of an abnormal protein called tau, which forms neurofibrillary tangles. Tau is also believed to be one of the culprits behind Alzheimer’s disease. Because similar regions of the brain tend to be affected, most individuals display these characteristic symptoms.
As public awareness of the links between repetitive brain injury, football, and CTE grew in the early 2000s, things began to change in the NFL. In 2009, the league introduced concussion protocol.
It was also around this time that Texas Tech University head coach Mike Leach was featured on the front page of The New York Times for having abused a player with a concussion by confining him to a small, dark space while the rest of the team practiced. Leach was fired.
The world was finally beginning to take notice—and action.
Fast forward to 2017, when a groundbreaking Boston University study was published in the Journal of the American Medical Association. Out of 111 former NFL football players who displayed symptoms of CTE at death, 110 were found to have diagnostic criteria of CTE from brain autopsies revealing tangles of tau protein.
The ages of the NFL players, whose brains had been donated to science by family members, ranged from as young as 23 to as old as 89. The study encompassed all player positions. Most notably, 44 lineman, 17 defensive backs, 10 linebackers, and seven quarterbacks.
I remember reading about this study while gearing up for my fourth and final season on the gridiron at Montana State. The finding was monumental—an irrefutable argument that football caused CTE.
Or did it?
When it comes to CTE and football, the relationship isn’t black and white
The issue with the 2017 study and, really, much of the CTE research up to this point, comes down to who was included—and who wasn’t.
These brains had been donated by families for evaluation specifically because they displayed the characteristic symptoms of CTE from players with known head trauma.
“It’s biased sampling,” says Steve Kernie, M.D., professor and chief of Critical Care and Hospital Medicine at New York-Presbyterian Morgan Stanley’s Children Hospital, whose research focuses on brain self-repair following injury. “It’s hard to make really strong conclusions other than players in contact sports who have repetitive head trauma are certainly at risk,” Kernie adds. “This is also something we’ve known for 100 years.”
A control group would be required to un-bias the data—such as adding into the pool of participants the brains of former NFL players who didn’t exhibit signs of CTE, plus the brains of non-athletes.
Kernie references a condition originally called “punch-drunk syndrome,” first described by American pathologist Harrison Martland in a 1928 Journal of the American Medical Association essay about the strange behavior of boxers—another brutal, beloved sport long associated with head trauma.
“For some time, fight fans and promoters have recognized a particular condition occurring among prize fighters which, in ring parlance, they speak of as ‘punch drunk,’ ” Martland wrote. “Fighters in whom the early symptoms are well recognized are said by the fans to be ‘cuckoo,’ ‘goofy,’ ‘cutting paper dolls,’ or ‘slug nutty.’ ”
A decade later, the term punch-drunk would be replaced by the more appropriate dementia pugilistica.
It’s important to point out that the link between repetitive brain injury and CTE isn’t exclusively associated with football or boxing. Other contact sports like soccer and wrestling have been implicated too.
There are also documented cases of CTE resulting from military blast injuries.
“During the Iraq War, service personnel were coming back with symptoms that weren’t quite PTSD,” says Kernie, explaining a growing military merger with CTE in these cases, which hasn’t been nearly as mined by the media. “The NFL gets more attention than the military unfortunately,” says Kernie.
Back to my original question. Would I play football again?
The friendships and life lessons I gained from over a decade of tackle football have shaped the person I am today.
Moreover, while I believe the association between repetitive head trauma, football, and CTE is real, I think the general public has a skewed perception. The presence of a concussion or two doesn’t guarantee a diagnosis of CTE. Many other factors are likely at play—including adequate recovery after an initial concussion and genetic predispositions to the disease.
My own hindsight question about playing football is now being asked at the outset by parents who are nervous about signing their kids up for the sport.
The dwindling numbers are telling. Peewee football participation is at an all-time low. Meanwhile, the waning interest in football appears to be providing gains for soccer, which ironically is not without its neurological risks.
I asked Dr. Kernie what his advice would be to parents considering whether or not to let their children engage in contact sports—particularly football.
“As a parent of kids who played sports, I think you can’t live in a bubble,” he says. “Everything we do carries some risk. It’s really about mitigating those risks as best you can.”
One significant way to mitigate these risks, especially in youth football, is by delaying the tackle element.
My brothers and I began tackle football in fifth grade. If you asked us now, we would have all put off tackling until late middle school or even high school. Not just to minimize repetitive head trauma, but to first master other football skill essentials like body positioning, blocking technique, and hand-eye coordination. All of these skills can be developed through flag football.
As I see it, the focus for budding football players at a young age should be on developing those skills rather than celebrating the traditional physicality which inevitably comes later.
Despite the public’s skewed perception on the pervasiveness of CTE among football players, we can hopefully all agree on two things: First, minimizing repetitive head trauma. Second, tackling this problem progresses by delaying youth tackle leagues and promoting the fundamentals of a phenomenal sport.
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