On May 2, 2012, former San Diego Chargers linebacker Junior Seau was found dead in his Oceanside home from a self-inflicted gunshot wound to the chest. Seau’s death was not the first high-profile suicide from a former National Football League player, but his passing has been the most discussed, prompting questions about the health and safety of football players in the professional and amateur levels.
Seau was only two years removed from a stellar playing career when he died, but he was already showing signs of mental distress upon retirement before he decided to take his own life. The aftermath of Seau’s suicide lead the public and the media to question whether his mental problems were caused by his time playing in the NFL, and his death became the climax of an ongoing nationwide discussion about head trauma in football and other contact sports. The autopsy reported no alcohol or drugs found in his system (with the exception of zolpidem, a prescription sleep aid), negating any idea that substance abuse fueled his ultimate fatal decision, and further advancing the conversation of a link between football and brain damage.
Seau’s family sent his brain tissue to the National Institute of Health for examination, and on January 10th, 2013, the family revealed that Seau had been diagnosed with chronic traumatic encephalopathy, more commonly referred to as CTE, the three letters that might spell the end of gladiator sports in the United States.
“Nobody really knows why it breaks.”
As of today, CTE can only be diagnosed post-mortem, possibly the scariest aspect of an already frightening disease. Another troubling truth is that the symptoms of CTE (memory loss, mood swings, depression, loss in motor skills) look almost exactly like symptoms of Alzheimer’s disease. Unlike the fight against Alzheimers, however, doctors have a general idea about the cause of CTE: repeated violent hits to the head. The consensus is that a person who limits head trauma will avoid CTE, but that is where a comprehensive understanding of the disease ends.
No one in the country knows more about head trauma in athletes than Dr. Ann McKee, the country’s most famous neuropathologist. Dr. McKee works in a laboratory at Boston University and has been designated as the NFL’s official post-mortem brain examiner. She has been gifted dozens of brains of former athletes (many of which she has diagnosed with CTE) and has been promised over 500 more from former athletes willing to donate their brains in the fight against this disease.
One of these brains belonged to Derek Boogaard, an enforcer in the NHL who died from a drug overdose recovering from one of his many concussions suffered during his playing career. Another belonged to Owen Thomas, a student-athlete on the University of Pennsylvania football team who hanged himself in his dorm room after a severe state of mood swings and depression. The most shocking brain belonged to Eric Pelly, a straight-A Pennsylvania high school student-athlete who was only eighteen years old when he took his own life.
McKee diagnosed CTE in fourteen of the first fifteen damaged brains she was given. Some of these brains belonged to boxers, some to football players, a couple of them to hockey players, and one to a soccer player. Some of these players were years removed from playing the sport that ultimately caused their downfall; some of them were just beginning. Some of them suffered silently for decades and lived full lives before ultimately succumbing to death, and some of them died without knowing there was a clinical problem.
As Jonah Lehrer wrote for his piece on head trauma in high school football players for Grantland: “Sometimes players walk away from savage hits. And sometimes they are felled by incidental contact…there is no clear threshold for injury.” The only thing these fourteen brains had in common were repeated hits to the head suffered on the field of play and the little black spots in the cerebral cortex that spelled doom for these players. “The mind remains a black box; nobody really knows why it breaks,” wrote Lehrer, “But we do know what happens once it’s broken.”
“At some point, there’s a switch.”
To know CTE, one must first understand the way of Tau. Tau is a protein that serves as scaffolding inside of brain cells, acting as a structure that supports neurons and promotes healthy function. Dr. McKee and other neuropathologists look for congregations of broken down Tau, which can appear as black or dark brown spots in brains suspected of suffering from CTE. Athletes who treat their heads like wrecking balls will eventually break down the scaffolding in their brain cells and cause the Tau protein to turn against the neurons.
Unfortunately, the construction metaphors break down with further research. While true that repeated hits to the head eventually causes Tau to break down, researches have not found a clear pattern that can help us correctly diagnose CTE in a living brain. “This issue is that there’s a lot of variability between people,” says Dr. Michael Marvi, a neurologist working as a clinical examiner of patients with concussions in Burbank, California. According to Dr. Marvi, the brain doesn’t follow a predicted pattern of deconstruction like a building demolition, but rather stops functioning as a result of Tau buildup at an unpredictable point. “At some point, there’s a switch, and these proteins break down and accumulate within the cells, and it is this protein buildup that is thought to be toxic both to the neighboring cells and within the cells. It’s not entirely clear what the mechanism is.”
Dr. Marvi has noticed patterns in his clinical work that give him a few suspicions about the variability of the brains he works with. “There may be some genetic propensity for developing not just post-concussion syndrome, but possibly CTE…people with pre-existing migraines, for example, tend to heal slower from a concussion than people without chronic headaches.” The impression Dr. Marvi gave about traumatic brain injuries is that the cause and the ultimate effect of the injuries are well-studied and understood, but it’s the middle part, the critical section of time that may be able to shine a light on a cure or even a prevention, about which we know very little.
“…a piece of information they wouldn’t otherwise have.”
Preventing concussions in sports is a lot like preventing unwanted pregnancy: the only foolproof answer is abstinence, though many people choose to ignore that fact. The Boston University School of Medicine advises that no child under fourteen years old should be allowed to play football, though Dr. Marvi believes that threshold should be lifted to sixteen years old. Many experts believe the costs outweigh the benefits in amateur contact sports, but many athletes and parents of athletes choose to ignore the advice.
When we talk about preventing concussions in sports, the conversation inevitably turns towards headgear. Plastic helmets have been one of football’s greatest lifesavers; it has been reported that in 1905, for example, twenty college football players died on the field of play, mostly from skull fractures and cerebral hemorrhages caused by violent hits to unprotected heads. The modern well-fitted football helmet combines a hard plastic shell used to diffuse the energy of the hit with a soft padded lining that cushions the head and prevents the skull from breaking. As a result, on-field deaths from blows to the head have plummeted, making modern football a markedly safer game than the game played before the introduction of the modern helmet.
There are a few caveats to the modern helmet, however. For one, helmets give players a misguided sense of protection and an excuse for players to use their heads as weapons. For another, players have gotten bigger and faster over the years, and helmet technology hasn’t caught up to the growth and speed of the modern athlete. The most concerning problem, however, is that whatever energy the skull doesn’t absorb from the hit forces the brain to knock against the skull, often multiple times during a hard collision. As a result, hard hits act as indirect punches to the brain, the biggest cause of concussions in football. The modern helmet prevents a skull fracture, and it may be possible (though highly unlikely) that one can be developed to prevent concussions, but a helmet that can prevent both isn’t feasible.
Riddell, a sports apparel manufacturer that supplies two-thirds of all NFL players with helmets, is leading the charge to produce the safest helmets possible. The company will soon release their new SpeedFlex helmet, a standard football helmet equipped with sensors that can deliver a message to the sideline when a blow to the head is alarmingly forceful.
Though this helmet provides a useful tool in the fight against head trauma, the company remains realistic regarding the development of these “smart” helmets. Riddell spokesperson Thad Ide said, “(This helmet) doesn’t diagnose concussions or any head injury. It gives (coaches and trainers) a piece of information they wouldn’t otherwise have.” Smart helmets may be able to notify athletic trainers about dangerous hits, and the trainers can then possibly prevent further damage, but as long as the structure of the helmet remains the same and the athlete plays the same football that has been played for the last century, there is little Riddell or any company manufacturing helmets can do to prevent the problem.
“You can’t decelerate the brain.”
As of right now, much attention is being paid to recognizing the symptoms of on-field concussions and treating athletes before any further injury is suffered. Much ado was made about the NFL’s concussion protocol implemented in 2013, a protocol that was replicated in the NBA, NHL, and MLB soon after, and a system that has been implemented in amateur football across the country.
Coach Eli Hallak, A.T.C., an athletic trainer at St. Francis High School in La Cañada, California, is the head of one of the nation’s top high school sports medicine programs and stresses the importance of prevention and maintenance of head injuries in his Kinesiology course and nationally renowned student athletic trainer program. The concussion protocol he follows is very similar to the protocol followed in professional sports.
“We do a sideline evaluation,” says Coach Hallak, “and check for memory, balance, reflex, and cognition.” The NFL and NHL mandate that all checks be done in a quiet, dark space (usually in the locker room), but otherwise the evaluation is very similar to the one performed in California. In 2012, California state law mandated that any athlete suspected of suffering from a concussive blow must be removed from the field of play immediately and cannot return until he/she is cleared by a doctor trained in concussion maintenance and therapy. Before then, doctors could diagnose grades of concussion (grade one mild; grade three as severe) and determine the length of time an athlete needed to sit out. “Now, it’s like pregnancy,” says Coach Hallak, “either you’re concussed, or you’re not.”
St. Francis uses a computer program known as the ImPACT test to determine the severity of each brain injury. The ImPACT test, an industry standard even in the professional game, is taken by players at the beginning of the year to determine an athlete’s individual level of memory and response time. If a brain injury is suspected, the athlete can perform the same test post-injury to determine whether brain function has been severely compromised. “It’s a phenomenal tool,” says Coach Hallak. “We used to evaluate players by going through a series of memory tests and simple addition/subtraction problems…but what if one player is really good at math? That affects the test.” Dr. Marvi also believes that ImPACT is a useful tool. “If they are symptomatic, and there is a large drop off in the test score, then it is likely that they have suffered a concussion.”
Though useful and almost universally utilized, ImPACT cannot diagnose a concussion, much less CTE or any other neurological disorder. It may be as of right now the most useful piece of technology in the effort to prevent CTE, but it doesn’t come close to solving the main problem. “You can’t decelerate the brain,” says Coach Hallak, “there’s no way to make that happen.”
“Who’s going to pay for it?”
One of the few bright spots in the fight against CTE is strong forward momentum in research. Though there is no way to diagnose the disease in a living brain, researchers hope that they will be able to find triggers that reveal the disease in the bloodstream or on brain scans within the next few years.
Researchers at the University of California at Los Angeles (UCLA) have developed an imaging protocol that could be modified to search for buildup of Tau within the next few years. Researchers are also looking at certain bile markers from blood samples that would be able to signal whether a significant brain injury has been suffered. Already existing technology like diffusion MRI can be used to detect subtle changes in white matter, which may be able to reveal signs of brain injury. Diffusion MRI (also known as DTI) detects changes in water diffusion across membranes of the cerebral cortex, which can lead to a better understanding of metabolic changes in the brain. DTI is mostly used for patients who suffer from a stroke or other more common neurological conditions, but recently it has been tested on patients with traumatic brain injuries. DTI, though not entirely effective, is the best available technology to detect signs of CTE. For most people, however, its use isn’t economically feasible.
“The issue is cost versus benefit,” says Dr. Marvi. He says that while the technology can be used effectively, insurance companies refuse to cover DTI scans for CTE screenings. “There is no evidence that it actually changes management or care.” He remains hopeful that insurance companies will one day subsidize a better scanning protocol, but the cautious way insurance companies handle the current treatment procedure gives him reason to be skeptical. “I am hopeful that all of these technologies will be available,” he says, “the question is: who’s going to pay for it?”
Head Injuries Across Sports
Football isn’t the only sport with a concussion problem (women’s soccer has a concussion rate twice as high as men’s soccer, for example, and no one seems to know why), but it isn’t a stretch to say that concussions are a football problem. High school football has by far the highest concussion rates of any amateur sport and professional football has by far the scariest anecdotal evidence advocating against violent head-to-head collisions. Tools and protocol measuring the severity of concussions already exist and have been implemented, and tools to diagnose more effectively CTE and other neurological disorders are only a few years away.
But these don’t address, much less prevent, the cause of this debilitating disease. It’s been said many times, but it’s an aphorism that still merits repetition: the biggest danger to football players is football itself. No helmet regardless of technological advancements will prevent a brain from bouncing off its skull. Researchers may be able to find and diagnose the disease in living brains within the next few years, but as of right now there is little that can be done to reverse or cure the disease once it is diagnosed. As long as the only real solution to the CTE problem in athletes is a systematic overhaul of sports that the American public does not want to change, players will continue to suffer from life-threatening and entirely preventable brain injuries. Technology can only do so much.