CTE in Football: What Don’t We Know, and How Do We Get There?

Head trauma is far from a hard science.  In football, where aggressive contact in the norm, the medical community is working to determine an understanding of proper prevention, treatment, and a working knowledge of how the sport influences the development of CTE or similar symptoms. I spoke with three specialists in the field of head trauma at the University of Florida and several college football players. Below is an introductory survey of both the similarities and differences in professional opinion of CTE and its relationship to football.

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The National Football League has had a contentious relationship with the medical community when it comes to Chronic Traumatic Encephalopathy – the degenerative brain disease better known as CTE.

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Just last month, the NFL publicly acknowledged a link between football and CTE when Jeff Miller, the NFL’ Senior Vice President of Health and Safety Policy, addressed the issue.

Per CNN, Rep. Jan Schakowsky asked him directly: “Mr. Miller, do you think there is a link between football and degenerative brain disorders like CTE?”

Miller’s direct, affirmative response was echoed by the NFL as accurately reflecting the league’s views – especially in light of Dr. Ann McKee’s latest research with Boston University.

However, Dallas Cowboys owner Jerry Jones refuted those statements just a week later, explaining that there wasn’t enough evidence to confirm any kind of link, per Sports Illustrated. Indianapolis Colts owner Jim Irsay had a similar take when he explained that there was still much to learn about any potential link to the Sports Business Journal.

Even without wholly denying a connection between the sport and the brain disease, both owners have caught flak. That being said, they’re not completely wrong.

The evidence and research, at this point in time, is full of just as much speculation as there is concrete findings – probably more.

At the University of Florida, there was certainly a level of common ground in understanding between doctors and specialists.  And yet, the discrepancies leave room for doubt.

“The studying of CTE is still in its infancy (in human and animal models),” said Dr. Kevin K. Wang, director of the program of Neurotrauma, Neuroproteomics, and Biomarkers Research (NNBR). “So, expect a lot of noise and conflicting information to come out in the next five years.”  Both Doctor Jay Clugston – an expert on concussions as a physician for the University Athletic Association – and Doctor Steven DeKosky – the Deputy Director of the McKnight Brain Institute at UF – echoed this expectation for inconsistencies.

With so many unknown variables up in the air, all three doctors determined that there was a need for larger sample sizes across larger groups of people.  Because these don’t exist yet, it’s difficult to illustrate more than an abstract difference between causes.

Dr. Wang delved more into the scientific research he believed would be needed, calling “longitudinal studies” – individual studies over a course of many years – a necessary method to analyze the causes and effects of CTE.  More so than what the other two doctors indicated, it’s a suggestion that may mean a lack of complete knowledge for quite some time.

But how to athletes enter the equation?  Football players, more than virtually any other sport, repeatedly deal with blows to the head.  It is a gladiatorial competition build on aggression and leverage.  Head injuries, most certainly among linemen, are nearer to commonplace in football than in just about any other career field in existence.

The types of blows that these athletes suffer range from subconcussive hits – small, repetitive trauma from continuous head contact – to varying degrees of concussions.  Factors such as severity and quantity of these injuries are thought to be influential in how someone’s brain health if affected, but the extent to which this is true is cloudy.

Reported concussions leading up to the 2013 season.

Reported concussions leading up to the 2013 season.

Natural aging?  The average person may suffer one or two concussions in a lifetime, yet “it seems few go on to develop clinical symptoms suggestive of CTE,” Dr. Clugston said.  Dr. DeKosky pointed to the idea that age changes the brain, making it naturally “more susceptible to injury.”  The conversation turned even more ambiguous when he pointed to the fact that “there are people who are mysteriously susceptible at an early age.”

Mysteriously.  Do genetics affect the cognitive state in more ways than we know for sure?

It’s the point at which most concrete evidence flies out the proverbial window.  When talking about this discrepancy between football players and the average non-athlete, the idea that more information is needed seems to be almost universally accepted.

Yet, with so little information, how do doctors relate to the football coaches, parents, and players that may come with questions and concerns?  It’s a tricky situation.

All three doctors expressed a concern for risks faced by young athletes, especially football players.  “Coaches, athletes and parents should weigh the positives and potential negatives of participation,” said Dr. DeKosky.  He also suggested those associated with the sport be open to rules changes and improvement in techniques as the medical community becomes more educated.  Although left unsaid explicitly, prevention appears to be just as important as treatment.

And when it comes to speaking with parents and coaches about prevention, it’s largely about identifying the current perceived risk – and more importantly, helping them understand that this “risk” isn’t a hard science.

An unexpectedly-high number of college football players I spoke with had dealt with some kind of serious head trauma.  This was usually quantified by whether trainers had diagnosed them with a concussion in games or practice.

Kolby Griffin, a defensive back for Kentucky State, suffered multiple concussions.  Despite this, he didn’t search for any opinions outside of his trainers on the team, who compared his baseline test to the one he had completed prior to the start of the season.  He was back to playing within a few days after each one.

Mike Williams, another defensive back — but for Lock Haven University — actually lost memory of the full two weeks leading up his concussion. It slowly returned to him over the course of the following days.  And yet, “injuries are a part of the game,” he told me.  “So, that’s how I treated my concussion.”  He also said that he didn’t seek any advice in addition to what his trainers told him.

In his case, and the case of James Tabor of Friends University, both returned after at least a week off from any kind of contact.

The differences in severity in a single concussion, such as that between Williams and Tabor still doesn’t have a defined correlation to any difference in future symptoms, according to implications made by Dr. DeKosky.  The effects on an athlete that suffers more head trauma deemed concussive, such as Griffin, are equally speculative.

In terms of future progress, all three doctors had high hopes for advancements down the road.  For Dr. Clugston, it’s a matter of becoming “objective” in our treatment and understanding.

“Hopefully we have an objective marker of brain injury for subconcussive and concussive impacts, as well as objective ways to assure people are recovering,” he said.  “Right now we rely on self-report of symptoms and functional testing, most of which can be manipulated by the patient.”

He said an “objective measure” where we could identity an athlete’s health anywhere on the spectrum from diagnosis of head trauma to when they return to the field would be “a major breakthrough.”

Objectivity, for all three, is an important goal to reach for our overall knowledge as well.  As Dr. Wang said, we should expect to find inconsistencies in research progress from different doctors and specialists.  Reaching a point where there is a concrete scientific understanding to head trauma is the goal.

For an understanding that may differ based on the cognitive state of any given individual – with any given number of variables in play for each case study — we very well may be a ways off from reaching those goals.  That being said, it’s become a primary focus for many sports physicians and neurologists in the medical community.

For concussion studies, it’s just as important to consider what we don’t know as much as what we do.

Let us know what you think!