CTE or no CTE, that is the question
I began noticing an interesting phenomenon a few years back. I was working at a Sports Medicine clinic seeing an increasing number of patients suffering from sport-related concussion. More and more patients walked into clinic not so concerned for their immediate neurological status, but for an impending demise crudely awaiting them at some point in the future.
According to the International Consensus Statement on Concussion, a sport- related concussion is, “ A traumatic brain injury induced by biomechanical forces. These forces do not necessarily need to be the result of a direct blow to the head. Often times the blow can be elsewhere with the impulsive forces being transmitted to the head.”
Typically, the patient experiences a relatively short-lived impairment of neurological function ( never feels short-lived) with the presence of physical, cognitive, emotional and sleep disturbance symptoms. In a clinical best case scenario a brief period of inactivity is followed by a structured return to activity. Seven- ten days after the initial injury, the patient briskly bounds into your office, bottle of wine in hand thanking you for your servitude to humanity with any traces of concussion long gone.
Problem is, within that seven-ten day period an increasing number of patients were coming into the office asking fearfully about CTE.
“This is my third concussion am I going to get CTE?” Or, “My daughter is really struggling right now and I’m worried about CTE.” The media added fuel to the combustible fire with tragic reports of suicide followed by neuropathological findings using the now ubiquitous acronym CTE.
CHRONIC TRAUMATIC ENCEPHALOPATHY
Chronic Traumatic Encephalopathy (CTE) is a progressive neurodegenerative disease primarily involving a specific brain protein called Tau. Normally a trustworthy soluble protein, Tau provides a great deal of stability and support to the 85 billion or so neurons in your brain. During the progression of CTE those once stable, soluble tau proteins start clumping together and ravaging their way through healthy brain tissue.
It is important to understand that CTE is not new. Pathologist Dr. Harrison Martland first described this particular pathology in a group of professional boxers in 1928. Martland had performed a series of autopsies and noticed that a number of haemorrhages were attributed to small vascular injuries in overly- punished boxers who had been suffering from neurological symptoms. These boxers and his subsequent paper were aptly titled, “Punch Drunk.”
Fast forward to today. CTE has been seen in adolescents but most people usually do not experience symptoms until years after the onset of head impacts. Initial symptoms often effect mood and changes in behaviour are quite common. As the disease progresses so do the symptoms. Memory loss and confusion become indicators that this destructive pathology has worked it’s way into vital brain areas such as the hippocampus- a structure shared across vertebrates important in the consolidation of short-term to long-term memory as well as spatial memory and navigation.
Concussion and CTE are now synonymous with each other. Will Smith starred in a Hollywood blockbuster playing the role of forensic pathologist Dr. Bennet Omalu who discovers the same pathological findings as Dr. Martland years prior. Findings that the NFL would continue to dismiss for years to come.
My problem with the movie? It has nothing to do with its title, “Concussion”. The movie is a tragic tale of the devastation caused by CTE, not concussions. There is no evidence today suggesting that CTE is caused by a single blow to the head. Importantly, current research cannot even correlate a certain number of concussions to CTE. There have even been cases of CTE in athletes that have never sustained a concussion.
Research over the last decade has indicated that repetitive subconcussive trauma over time is the strongest correlator with CTE. Subconcussive hits may alter both the structure and function of the brain resulting in small amounts of trauma that build over time — time and trauma pathologically cooperating to alter the brain in a way that ends abruptly much too often.
To sum it up: the athletes who took more hits over a longer period of time were at greater risk for problems later in life. This then begs the obvious question for those wanting to remain in sport, “ What can I do to prevent the accumulation of subconcussive hits?”
- Introduce age appropriate rules for contact: Delaying the introduction of contact can limit the time an athlete is exposed to potential trauma. This is obvious in sports like football, hockey and rugby with its inherent physicality, but less so in soccer. US Soccer is limiting contact not with other players, but with the ball, “ There should be no heading for any players age 10 and under, while limiting the amount during practice for those ages 11 to 13.”
- Eliminate unnecessary contact/exposure: Devices that measure impact, acceleration and rotation are being installed in athlete helmets to determine hit/contact profiles for both individual players and teams. Blast sensors are also being used in a military setting to determine how shock waves alter brain function and cause potential injury. The data gathered from these sensors can then be used to determine individual risk profiles as well as gather information about exposure on a larger scale. While the field is a nascent one and I wouldn't rush out to throw an accelerometer into my son’s helmet, the data being gathered is undeniably helpful.
- Coaching contact: All sports involve movement and many involve contact. On field evaluations by qualified folks can identify those at greater risk for sustaining trauma, hits, injury etc. This is where proper coaching, conditioning, technical training and strengthening strategies should be implemented to help reduce contact and risk of injury. For example, a 16 year-old football player with little to no strength training, poor movement patterns/flexibility and incorrect tackling technique is going to show terrible helmet data. This is 100% correctable and can be implemented ASAP. One team leading the charge with such interventions is a group out of Kingston, Ontario called Elite NeuroKinetix
BACK IN CLINIC
The conversation often shifts to one of, “Well should I even be playing sports if subconcussive hits are putting me at risk?” While context is key and the answer is never a simple yes/no, I can confidently say the goal should be to keep people playing sports. The benefit of sport transcends the biological aspects of health and fitness and has the ability to reward us psychologically and sociologically as well. We simply want to keep athletes on the right side of a risk- reward scenario that focusses on both the enjoyment of sport as well as player safety.
While the nervousness pertaining to CTE may always exist, a discussion of the recent research with all its advantages and limitations is usually a good place to start. Education has a profound ability to empower the athlete and shift the narrative to efforts regarding improving player health, safety and resiliency. As the education continues and the symptoms ameliorate you can watch as the confidence returns to those once photosensitive eyes.
At the onset of the injury, what looked to be a future confined to darkness (both literally and figuratively), silence and pain is supplanted by knowledge, strength and hope. This is what returns us to the field and keeps us playing.