The Super Bowl is this Sunday: Let's talk CTE

Looking back at my career as an amateur athlete, I've had five concussions and a lot of repetitive minor blows to the head. Most of these injuries occurred playing sports in high school and I have not suffered a significant blow to my head after age 35. I have no idea as to whether I have any demonstrable brain lesion due to these traumas incurred in competitive football, wrestling and recreational snowboarding and cycling (injuries occurring in the latter two while wearing a helmet). I don’t believe I have any lingering neuropsychiatric deficits. I am lucky. Chronic traumatic encephalopathy (CTE) has been defined as a progressive neurodegenerative disease caused by repetitive head trauma. CTE was first described back in 1928 when Dr. Harrison Martland, a New Jersey medical examiner, began to note a constellation of symptoms in boxers. The initial term “punch drunk” was refined to dementia pugilistica and over the decades more scientific knowledge has emerged. Almost a hundred years later, we have noted this condition in athletes playing football, hockey, rugby wrestling and extreme sports. It has also been confirmed in military personnel where repetitive sublethal blows to the head occurred over time. A very succinct article published in 2017 by Craig Lindsley gives an excellent historic overview of CTE. “The symptoms of CTE begin to emerge 8–10 years after experiencing repetitive head injury (RHI), and include headache, personality changes, impulsivity, irritability, short-term memory loss, aggression, depression, parkinsonism, speech and gait abnormalities, and suicidal thoughts and actions,” the article reads. “While bearing some overlap with Alzheimer’s disease (AD), amyotrophic lateral sclerosis (ALS), Parkinson’s disease (PD), traumatic brain injury (TBI), and numerous other neurodegenerative disorders, CTE is distinct.” The link to professional football, and high profile attention from the media, began with a report from Dr. Bennet Omalu and co-workers in 2005 that CTE was diagnosed postmortem in a symptomatic NFL football player, and he highlighted a second NFL player the following year. In 2009, Dr. Ann McKee and co-workers reported on five NFL players with classical symptoms (depression, memory loss, paranoia, aggression, confusion and agitation) that were neuropathologically verified with CTE at autopsy. These findings led Dr. McKee and co-workers to pursue a larger study of 85 subjects with RHI and displaying classical CTE symptoms. In July 2017, Dr. McKee and co-workers published a landmark paper in JAMA that took the world by storm. In one of the largest CTE studies to date of all levels of football players (202 subjects), 86% (177 subjects) were neuropathologically diagnosed with CTE. More than five years later we are still debating this topic. An excellent 2022 article in the Washington Post about former NFL star Demaryius Thomas being diagnosed with stage II CTE brings us up to date with the current state of affairs. “Like so many that have gone before, we found Stage 2 CTE in the brain of Demaryius Thomas,” Dr. McKee said. “The question I keep asking myself is, ‘When will enough be enough?’ When will athletes, parents and the public at large stop ignoring the risks of American football and insist that the game be changed to reduce subconcussive hits and that the athletes be comprehensively evaluated at the beginning and end of every season?” The public is aware but seemingly still turning a blind eye to this subject. Even a 2015 Hollywood movie Concussion a “biographical sports drama” starring Will Smith, failed to outrage enough people to make real changes. If football is among the highest risk collision sports, what has the NFL done to try to mitigate this? Well . . . apparently, they have attempted to work with helmet manufacturers and have modified their concussion protocols and made them stricter. But it doesn’t appear that they have really done much at all. If anything, they'e continued to obfuscate the EBM link between the sport and the violence experienced by, early dementia and death of its players. What has the Canadian Football League done recently? In 2018, “In his first official statement, the Canadian Football League’s new commissioner Randy Ambrosie rejected the link between contact sports and brain damage”. It appears that Canadian researcher Dr. Neil Vasdev, director of the Centre for Addiction and Mental Health Brain Imaging Centre is making more strides with military veterans. Dr. Vasdev and his team are doing ground-breaking work in making the connection between repetitive concussive trauma and mental health. We now have compelling science. So, what is the disconnect? Super Bowl Sunday is watched by nearly 100 million Americans. It’s the most anticipated, most hyped annual sporting event. Football fans are, well, fanatical. College football is massive and pro football is an incredibly lucrative business. In 2021, the 32 teams of the NFL generated revenue of 17.19 billion U.S. dollars. In the end, it’s all about the money and the refusal of letting anything get in the way of this money-making machine. Daniel Sailofsky’s article in the Guardian says it all. The “NFL season is here but I won’t be following anymore. I can’t un-see the harm it causes.” “High contact sports like football have long been associated with a domineering, patriarchal form of masculinity linked with violence and misogyny,” he writes. “Combine this culture with abusive coaching, high rates of brain injury and concussion, and a win-at-all costs ethos that ignores the mis-behaviour of players as long as they perform on the field, and the NFL can be considered complicit in the ongoing violence committed by players.” Sailofsky recognizes the complexities and nuances of a highly paid sport which defines American culture. “Given the current structure of the American sport and education systems, I know that football is sometimes the way certain oppressed groups can access college. For many, football is seen as a “way out.” Football does bring communities together and teaches some young men about resilience, leadership and hard work. But these positive outcomes do not wash away the harms, and maybe just as importantly, these positives can be accomplished in a variety of other ways, none of which involved brain injury, violence or exploitation.” I am just scratching the surface of this controversial topic. As a medical community, are we doing enough to protect our athletes and their futures? In the Canadian context, our kids continue to play ultra-competitive and collision-prone hockey. We have learnt, but when are we going to take decisive action to change the trajectory leading to CTE? I welcome comments. Dr. Ted Jablonski is a singer-songwriter, emerging playwright and neophyte poet who has retired his family practice to focus on sexual medicine and transgender health in Southern Alberta. He finds himself advising medical students at the Cumming School of Medicine and still on the front-line trenches of acute primary care.

The Super Bowl is this Sunday: Let's talk CTE

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