Jeffrey Bland (PhD) critiques the sports media for underplaying a landmark JAMA study (July 25, 2017) that examined chronic traumatic encephalopathy (CTE) via postmortem brain analyses of 202 former football players. He summarizes key findings: diagnosis used blinded postmortem consensus criteria focused on phosphorylated tau deposition, lesions concentrated at depths of cortical sulci/perivascular regions, graded stages 1–4, a suggested dose–response (more years/level of play → more severe pathology), mean age at death overall ~66 years (stage-specific means: mild ~44; severe ~71), and 27% with suicide as cause of death. Bland highlights unanswered questions (prevalence in random samples, role of genetics/lifestyle, thresholds of exposure) and argues the findings have major implications for sport safety and legal liability.
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Well, I'm back one day after our report of the landmark JAMA article in the July 25 issue, 2017 entitled Clinical Pathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football. And I was very interested to see how this would play in the media because it's a major significant medical finding that has implications across one of the most popular sports in America, American football. And I was very, I think, surprised at the low key way that this extraordinary study was described in much of the sports media yesterday. In fact, I heard commentators say things like, well, it's well understood that if you play football you're going to hit your head, you're going to have problems. And that just comes along with the condition of playing football. And so why is this anything big deal? It is a big deal. It's a huge deal. And let me tell you why. And I think there's probably some vested interest that's being expressed by those that don't want to take this as seriously as it should be taken. So let's actually go back to the article for a second and just talk about some of the reasons why this is a big deal. As you know, this is a study done with anatomical sections of brains from deceased football players, from high school football, all the way up through professional NFL and Canadian Football League players. It is a study done at a very reputable institution across multiple experts. In fact, the authors in this study list more than 15 very competent people in neurosciences, neuroanatomy, pathology and with the major contributing author being Ann McKee from Boston University Alzheimer's Disease Center. And this work is exacting work because it really used the most contemporary diagnosis of neuropathology to assess the status of these former football playing athletes. It was 202 deceased athletes, as you recall. The mean average point at which they died I think is very notable. It's 66 years. And that was averaged among all of these 202. Those with the mild, this was graded in four different grades from one to four, four being most serious. The mild individuals are the individuals that had a very interesting statistic because their major cause of death, which was at a younger age than that of the more severe forms, was 44 years of age, on average that they were found themselves. And they found that the most significant cause of death, in fact 27% of them was suicide. Yeah, that's right, 27%. Suggesting neurobehavioral factors could have played roles in those that had stage three and four. That was much more serious with many More signs of anatomical destruction and pathological destruction. The mean average age of death was 71 years. And in those cases they had much more evidence after longer impact and time of serious brain degeneration. This suggests a functional kind of dose response relationship, doesn't it? That the more years of exposure, the more years since exposure to a traumatic brain injury, the more time for degeneration to occur, the more serious the condition. It's like a dose response curve. And in fact, the way that they did the actual diagnosis was pointed out in a subsequent editorial in the JAMA. This appeared in page 338 of the issue. They said the diagnosis of CT in the study was made blinded to clinical information, applying recently published consensus criteria developed by a panel of experts convened by the National Institutes of Health. Postmortem diagnosis of CTA hinges on the presence of phosphorylate taurus, a protein that wind phosphorylate is associated with neurofibrillary tangles and increased apoptotic death to neurons. And they went on to say that it was found that these regions of injury in these former football players were at the depths of the cortical sulci in the perivascular regions. And this turns out to be of anatomical importance because, as it points out, biomechanical studies suggest that these regions are particularly susceptible to stress and strain forces when exposed to rapid acceleration deceleration, providing a potential mechanistic link between acute injury and the distribution of tau aggregation that was found in these CTE athletes. So you've got dose response, you've got an anatomical locus of injury, you've got the, the difference in frequency between high school football players. It had a much lower evidence of injury and a much less severe form of injury. And then you've got these more severe, longer term players in the NFL and the Canadian Football League with more serious injury resulting in what would be considered neuropathology associated with Alzheimer's, Parkinson's and other very serious neurodegenerative diseases. So, so this is more than just a small oh, we already knew study. This is a hugely important study with major implications about these sports that involve traumatic gravity related injury to the brain. And in fact, Dr. McKee was quoted as saying that there are many questions that remain out of this study. How common is it if we were to do a random sample of all football players, not just those that had donated their brains postmortem, for which they might have already had some concern about their neurophysiological and psychological effects, how many years of football are too many and what types of football and what types of injuries and then are there genetic risks or specific other factors? In fact, she goes on to say, and I found this very interesting, some players who play football for some duration don't have any evidence of neurodegeneration suggesting that there may be modifying or mitigating factors. It could be genetic in nature or it could also relate to lifestyle habits. According to Dr. McKee, alcohol, drugs, steroids, diet, might these somehow also contribute to increasing susceptibility to these gravity stress related injuries? So I think that if you ask legal liability questions about school systems that involve us sponsoring or being associated with schools that have high school football going on, this type of data changes the litigious nature of all of this area and will have a significant influence, I think, on how we view the protection against injury and the kind of sporting activities that relate to contact that can create repetitive injury that is not necessarily related just to concussion. I want to emphasize they didn't find a direct relationship between the demonstrated report of concussion, but rather it's the continued injury, some of it's sub concussive, that seems to be associated with the long term effects on neurodegeneration. So we shouldn't take this lightly. It shouldn't be swept under the rug. And I am saying shame on you sports media for not giving us the proper support and understanding and description that it really deserves as a moment of time where we need to stop and ask the question what is football going to look like in America in the years to come?
